ES2982897T3 - Use of telomerase inhibitor imetelstat for the treatment of myeloproliferative disorders and myeloproliferative neoplasms - Google Patents

Abstract

Provided herein are methods for reducing the proliferation of neoplastic progenitor cells and alleviating associated symptoms in individuals diagnosed with or suspected of having myelodysplastic syndrome. Also provided are methods for using telomerase inhibitors to maintain blood platelet counts in relatively normal ranges in the blood of individuals diagnosed with or suspected of having myelodysplastic syndrome. (Automatic translation with Google Translate, no legal value)

Description

DESCRIPTION

Use of telomerase inhibitor imetelstat for the treatment of myeloproliferative disorders and myeloproliferative neoplasms

FIELD OF INVENTION

This invention relates to telomerase inhibitor compounds for treating or preventing symptoms associated with myeloproliferative disorders or malignancies such as Essential Thrombocythemia (ET).

BACKGROUND

Hematologic malignancies are forms of cancer that begin in the cells of blood-forming tissue, such as bone marrow, or in cells of the immune system. Examples of hematologic cancers include acute and chronic leukemias, lymphomas, multiple myeloma, and myelodysplastic syndromes.

Myeloproliferative neoplasms, or MPNs, are hematologic malignancies that arise from neoplastic hematopoietic myeloid progenitor cells in the bone marrow, such as red blood cell precursor cells, platelets, and granulocytes. The proliferation of neoplastic progenitor cells leads to overproduction of any combination of white blood cells, red blood cells, and/or platelets, depending on the disease. These overproduced cells may also be abnormal, leading to additional clinical complications. There are several types of chronic myeloproliferative disorders. Included in the MPN disease spectrum are essential thrombocythemia (TE), polycythemia vera (PV), chronic myelogenous leukemia (CML), myelofibrosis (MF), chronic neutrophilic leukemia, chronic eosinophilic leukemia, and acute myelogenous leukemia (AML). A myelodysplastic syndrome (MDS) is a group of symptoms that includes cancers of the blood and bone marrow. Myelodysplastic syndromes (MDS) include diseases such as refractory anemia, refractory anemia with excess blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia (CMML).

Essential thrombocythemia

Circulating blood platelets are anucleated, although they retain small amounts of megakaryocyte-derived mRNA and a fully functional protein biosynthetic capacity (Gnatenko et al., Blood 101, 2285-2293 (2003)). Essential thrombocythemia (ET) is a subtype of myeloproliferative disorder, characterized by increased neoplastic proliferation of megakaryocytes, elevated numbers of circulating platelets, and considerable thrombohemorrhagic, not infrequently neurological, events (Nimer, Blood 93, 415-416 (1999)). ET is seen with equal frequency in men and women, although an additional female incidence peak at age 30 years may explain the apparent higher prevalence of the disease in women after this age. The molecular basis of ET remains to be established, although it has historically been considered a "clonal" disorder (El-Kassar et al., Blood 89, 128 (1997); "Evidence that ET is a clonal disorder with origin in a multipotent stem cell" PJ Fialkow, Blood 1981 58: 916-919). Aside from the exaggerated platelet volume evident in ET platelet subsets, the cells remain morphologically indistinguishable from their normal counterparts. There is currently no functional or diagnostic test available for ET and it continues to be diagnosed by exclusion of other possible hematologic disorders. Incidence estimates of 2-3 cases per 100,000 per year are consistent with other leukemia types, but prevalence rates are at least tenfold higher because of the low mortality rates associated with ET.

Current therapies for ET focus primarily on preventing thrombotic/hemorrhagic events and involve non-specific reduction of platelet levels in the blood. However, none of these existing therapies specifically target the neoplastic progenitor cells that drive the malignancy responsible for the disease state. For example, treating ET with cytotoxic chemotherapy eliminates the neoplastic cells while leaving residual progenitor cells in place. This results in new neoplastic cells arising from the progenitor cells and continuation of the disease state. Furthermore, many people with ET develop resistance to first-line treatments such as hydroxyurea or discontinue use of these medications altogether due to adverse side effects.

Polycythemia vera

Patients with polycythemia vera (PV) have a marked increase in red blood cell production. Treatment is directed at reducing the excessive number of red blood cells. PV may develop a late phase in its course that resembles primary myelofibrosis with cytopenias and marrow hypoplasia and fibrosis. The Janus Kinase 2 (JAK2) gene mutation on chromosome 9 that causes increased proliferation and survival of hematopoietic precursors in vitro has been identified in most patients with PV. Patients with PV are at increased risk for cardiovascular and thrombotic events and transformation to acute myelogenous leukemia or primary myelofibrosis. Treatment for PV includes chronic intermittent phlebotomy to maintain the hematocrit below 45% in men and 40% in women. Other possible treatments include hydroxyurea, interferon alpha, and low-dose aspirin.

Myelofibrosis

Myelofibrosis or MF, or primary myelofibrosis is a myeloproliferative neoplasm in the same disease spectrum as ET. Patients with MF often carry the JAK2 V617F mutation in their bone marrow. Occasionally, ET progresses to MF. JAK2 inhibition is currently considered a standard of care for MF in countries where ruxolitinib (Jakafi®), a janus kinase inhibitor, is approved. There is no evidence that JAK2 inhibitors, such as Jakafi®, selectively inhibit the proliferation of the leukemic clone responsible for the disease and therefore they cannot be “disease modifying”.

Acute myelogenous leukemia

Acute myelogenous leukemia (AML) is a cancer of the myeloid line of blood cells. AML is the most common acute leukemia affecting adults. Patients with AML have a rapid growth of abnormal white blood cells that build up in the bone marrow and interfere with the production of normal blood cells. The replacement of normal bone marrow with leukemic cells causes a drop in normal red blood cells, platelets, and white blood cells. Symptoms of AML include tiredness, shortness of breath, easy bruising and bleeding, and an increased risk of infection. As an acute leukemia, AML progresses rapidly and is usually fatal within weeks to months if left untreated. The standard of care for AML is chemotherapy treatment aimed at inducing a remission; patients may receive a hematopoietic stem cell transplant.

Myelodysplastic syndrome

A myelodysplastic syndrome (MDS) is a group of symptoms that includes cancers of the blood and bone marrow. Myelodysplastic syndromes (MDS) include diseases such as refractory anemia, refractory anemia with excess blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia (CMML). Immature blood stem cells (blasts) do not develop into healthy red blood cells, white blood cells, or platelets. The blast dies in the bone marrow or shortly after traveling into the blood. This leaves less room for healthy red blood cells, white blood cells, and/or platelets to form in the bone marrow.

Myelodysplastic syndromes (MDS) are a collection of hematologic medical conditions that involve ineffective production of the myeloid class of blood cells. Patients with MDS often develop severe anemia and require frequent blood transfusions. Bleeding and risk of infections also occur due to dysfunctional or low platelets and neutrophils, respectively. In some embodiments, the disease worsens and the patient develops cytopenias (low blood counts) caused by progressive bone marrow failure. In some embodiments, the disease transforms into acute myelogenous leukemia (AML). If the overall percentage of bone marrow myeloblasts increases over a particular threshold (20% for WHO and 30% for FAB), then transformation to acute myelogenous leukemia (AML) is said to occur.

What is needed, therefore, are new treatments for myelodysplastic proliferative disorders or malignancies such as ET, PV, MF, CML, and AML, and for myelodysplastic syndrome that target the neoplastic progenitor cells responsible for the malignant phenotype of the disease, particularly in individuals who are resistant or who experience adverse events as a result of undergoing commonly prescribed first-line therapies for this disorder.

US 2005/282893 A1 reports the use of suramin for the treatment of a patient with cancer. Baerlocher et al Blood (2012) 120(16): 1-16 and Blood (2012) 120(21): 179 report preliminary results from a phase II study describing that Imetelstat rapidly induces and maintains substantial hematologic and molecular responses in patients with Essential Thrombocythemia (ET) who are refractory or intolerant to prior therapy. Kakiuchi et al Cytologia (2010) 75(2): 2010 177-183 report the inhibition of human tumor cell proliferation by the telomerase inhibitor TELIN. Tauchi et al Blood 102(11):652a report the activity of a G-quadruplex-interactive telomerase inhibitor, SOT-095, against human leukemia cells and the involvement of ATM-dependent AdN damage response pathways. Brunold et al Blood (2011) 118(21):3843 report Imetelstat as a telomerase inhibitor and its role in inhibiting spontaneous growth of CFU-Megin vitro from Essential Thrombocythemia patients, but not from healthy individuals.

SUMMARY OF THE INVENTION

In accordance with the invention, there is provided a telomerase inhibitor for use in alleviating at least one symptom resulting from chronic myelogenous leukemia (CML) or acute myelogenous leukemia (AML) in an individual, wherein the telomerase inhibitor is imetelstat or a pharmaceutically acceptable salt thereof.

The individual may be diagnosed or suspected of having chronic myelogenous leukemia (CML). Alternatively, the individual may be diagnosed or suspected of having acute myelogenous leukemia (AML). In accordance with the invention, administration of the telomerase inhibitor to the individual is intended to reduce the proliferation of neoplastic progenitor cells.

According to the invention, the at least one relieved symptom may comprise enlarged spleen, splenic pain, anemia, bone pain, fatigue, fever, night sweats, weight loss, headache, dizziness, lightheadedness, chest pain, weakness, fainting, vision changes, numbness or tingling of the extremities, flushing, stabbing or burning pain in the extremities (erythromelalgia), nosebleeds, bruising, bleeding from the mouth or gums, bloody stools, or stroke. The at least one relieved symptom may be due to chronic myelogenous leukemia (CML). Alternatively, at least one alleviated symptom may result from acute myelogenous leukemia (AML), optionally wherein the at least one alleviated symptom may comprise enlarged spleen, splenic pain, anemia, bone pain, fatigue, fever, night sweats, weight loss, weakness, fainting, nosebleeds, bruising, bleeding from the mouth or gums, bloody stools, or stroke, suitably where the telomerase inhibitor may reduce the anemia.

In accordance with the invention, the individual may be resistant or intolerant to prior therapy based on non-telomerase inhibitors. The telomerase inhibitor may be used with a pharmaceutically acceptable excipient. The telomerase inhibitor may be formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation or intraocular administration. Suitably, one or more neoplastic progenitor cells may be contacted with the telomerase inhibitor.

In accordance with the invention, the effective amount of a telomerase inhibitor may be from 3.5 mg/kg to 11.7 mg/kg, from 5 mg/kg to 11.7 mg/kg, from 6.5 mg/kg to 11.7 mg/kg, from 7.5 mg/kg to 9.4 mg/kg, or from 9.5 mg/kg to 11.7 mg/kg.

According to the invention, the telomerase inhibitor may be imetelstat sodium, optionally wherein the effective amount of a telomerase inhibitor may be from 3.5 mg/kg to 11.7 mg/kg, from 5 mg/kg to 11.7 mg/kg, from 6.5 mg/kg to 11.7 mg/kg, from 7.5 mg/kg to 9.4 mg/kg or from 9.5 mg/kg to 11.7 mg/kg.

Aspects of the invention for which protection is sought are as defined in the appended claims. The disclosure that is not part of the invention provided herein discloses, among others, methods of using telomerase inhibitor compounds to treat and alleviate symptoms associated with myeloproliferative neoplasms such as essential thrombocythemia (TE), polycythemia vera (PV), and myelofibrosis (MF) by targeting the neoplastic progenitor cells characteristic of these diseases. The disclosure that is not part of the invention provided herein also discloses, among others, methods of using telomerase inhibitor compounds to treat and alleviate symptoms associated with myelodysplastic syndromes (MDS) such as, for example, refractory anemia, refractory anemia with excessive blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia by targeting the neoplastic progenitor cells responsible for producing the abnormally high number of cells characteristic of these diseases. References to methods of treatment in the summary and detailed description of the invention in this description should be construed as references to the compounds, pharmaceutical compositions, and medicaments of the present invention for use in a method for the treatment of the human (or animal) body by therapy (or for diagnosis).

Accordingly, in one aspect, provided herein are methods for alleviating at least one symptom associated with myeloproliferative neoplasms in an individual in need thereof, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administering the telomerase inhibitor alleviates at least one symptom associated with myeloproliferative neoplasms. In some embodiments, the symptom comprises headache, dizziness or lightheadedness, chest pain, weakness, fainting, vision changes, numbness or tingling in the extremities, redness, stabbing or burning pain in the extremities (erythromelalgia), splenomegaly, nosebleeds, bruising, bleeding from the mouth or gums, melena, or stroke. In some embodiments, the myeloproliferative neoplasms are, for example, essential thrombocythemia (ET), polycythemia vera (PV), myelofibrosis (MF), and acute myelogenous leukemia (AML). In some embodiments of any of the embodiments herein, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments of the embodiment, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^-P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^-P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In some embodiments of any of the embodiments herein, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits CFU-mega. In some embodiments, CFU-mega inhibition is independent of reduction in JAK2 allelic load. In some embodiments, the individual is resistant or intolerant to prior therapy without telomerase inhibitors. In some embodiments, the individual is a human.

Accordingly, in one aspect, provided herein are methods for alleviating at least one symptom associated with essential thrombocythemia in an individual in need thereof, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administering the telomerase inhibitor alleviates at least one symptom associated with essential thrombocythemia. In some embodiments, the symptom comprises headache, dizziness or lightheadedness, chest pain, weakness, fainting, vision changes, numbness or tingling of the extremities, flushing, stabbing or burning pain in the extremities (erythromelalgia), enlarged spleen, nosebleeds, bruising, bleeding from the mouth or gums, bloody stools, or stroke. In some embodiments of any of the embodiments herein, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10 to 20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments herein, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In some embodiments of any of the embodiments herein, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits CFU-mega. In some embodiments, the inhibition of CFU-Mega is independent of the reduction of JAK2 allelic load. In some embodiments, the individual is resistant or intolerant to a prior non-telomerase inhibitor-based therapy. In some embodiments, the prior non-telomerase inhibitor-based therapy is hydroxyurea, anagrelide, or interferon α-2B. In some embodiments, the individual is a human.

In another aspect, provided herein are methods for reducing the proliferation of neoplastic progenitor cells in an individual diagnosed with or suspected of having myeloproliferative neoplasms or myelodysplastic syndrome, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor reduces the proliferation of neoplastic progenitor cells in the individual. In some embodiments, the myeloproliferative neoplasms are, for example, essential thrombocythemia (TE), polycythemia vera (PV), myelofibrosis (MF), and acute myelogenous leukemia (AML). In some embodiments, for TE, the proliferation of neoplastic progenitor cells results in platelet counts of less than about 600 x 103/μl in the blood of the individual. In some embodiments, the proliferation of neoplastic progenitor cells results in platelet counts of less than about 400 x 103/μl in the individual's blood. In some embodiments of any of the embodiments herein, the individual does not experience a thromboembolic event. In some embodiments of any of the embodiments herein, the reduced neoplastic cell proliferation resulting in platelet counts of less than about 400 x 103/μl in the individual's blood occurs within 2 months of starting administration of the telomerase inhibitor. In some embodiments of any of the embodiments herein, the reduced neoplastic cell proliferation resulting in platelet counts of less than about 400 x 103/μl in the individual's blood occurs within 1 month of starting administration of the telomerase inhibitor. In some embodiments, the individual is resistant or intolerant to prior non-telomerase inhibitor therapy. In some embodiments, the proliferation of neoplastic progenitor cells results in platelet counts greater than about 100 x 10 /L in the blood of the individual. In some embodiments, such as in MF, the reduced proliferation of neoplastic progenitor cells results in a modified hemoglobin level of at least 90 g/L, or 100 g/L, or 1 l0 g/L, or 120 g/L. In some embodiments, such as in MF, the reduced proliferation of neoplastic progenitor cells results in a modified absolute neutrophil count of at least 1.0 x 10 /L or at least 2.0 x 10 /L. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In some embodiments of any of the embodiments herein, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits CFU-mega. In some embodiments, the inhibition of CFU-mega is independent of the reduction of JAK2 allelic load. In some embodiments, the individual is a human.

In another aspect, provided herein are methods for reducing the proliferation of neoplastic progenitor cells in an individual diagnosed with or suspected of having essential thrombocythemia, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor reduces the proliferation of neoplastic progenitor cells in the individual. In some embodiments, the proliferation of neoplastic progenitor cells results in platelet counts of less than about 600 x 103/μl in the blood of the individual. In some embodiments, the proliferation of neoplastic progenitor cells results in platelet counts of less than about 400 x 103/μl in the blood of the individual. In some embodiments of any of the embodiments herein, the individual does not experience a thromboembolic event. In some embodiments of any of the embodiments herein, the reduced neoplastic cell proliferation resulting in platelet counts of less than about 400 x 10/μl in the individual's blood occurs within 2 months of starting administration of the telomerase inhibitor. In some embodiments of any of the embodiments herein, the reduced neoplastic cell proliferation resulting in platelet counts of less than about 400 x 10/μl in the individual's blood occurs within 1 month of starting administration of the telomerase inhibitor. In some embodiments, the individual is resistant or intolerant to prior non-telomerase inhibitor therapy. In some embodiments, the prior non-telomerase inhibitor therapy is hydroxyurea, anagrelide, or interferon α-2B. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In some embodiments of any of the embodiments herein, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits CFU-mega. In some embodiments, the inhibition of CFU-mega is independent of the reduction of JAK2 allelic load. In some embodiments, the individual is a human.

In another aspect, provided herein are methods for maintaining blood platelet counts of less than about 400 x 10 /μl in the blood of an individual diagnosed with or suspected of having essential thrombocythemia, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor maintains the blood platelet count of less than about 400 x 10 /μl in the individual. In some aspects, the telomerase inhibitor is administered no more than once every two weeks. In other aspects, the telomerase inhibitor is administered to maintain blood platelet counts of between about 150 x 10 /μl to about 400 x 10 /μl in the blood of an individual. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGT-TAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In some embodiments of any of the embodiments herein, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits CFU-mega. In some embodiments, the inhibition of CFU-mega is independent of the reduction of JAK2 allelic load. In some embodiments, the individual is resistant or intolerant to prior non-telomerase inhibitor therapy. In some embodiments, the prior non-telomerase inhibitor therapy is hydroxyurea, anagrelide, or interferon a-2B. In some embodiments, the individual is a human.

Accordingly, in one aspect, provided herein are methods of alleviating at least one symptom associated with polycythemia vera (PV) in an individual in need thereof, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administering the telomerase inhibitor alleviates at least one symptom associated with polycythemia vera (PV). In some embodiments, the symptom comprises headache, dizziness or lightheadedness, chest pain, weakness, fainting, vision changes, numbness or tingling of the extremities, shortness of breath, weakness or tiredness, splenomegaly, nosebleeds, bruising, bleeding from the mouth or gums, or melena. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits erythrocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits UFC-eritoride. In some embodiments of any of the embodiments herein, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments, the individual is resistant or intolerant to prior non-telomerase inhibitor therapy. In some embodiments, the individual is a human.

Accordingly, in one aspect, provided herein are methods for alleviating at least one symptom associated with myelofibrosis in an individual in need thereof, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor alleviates at least one symptom associated with myelofibrosis. In some embodiments, the symptom comprises splenomegaly and splenic pain, early satiety, anemia, bone pain, tiredness, fever, night sweats, weight loss, weakness, fainting, nosebleeds, bruising, bleeding from the mouth or gums, melena, or stroke. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is from 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In some embodiments of any of the embodiments herein, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits CFU-mega. In some embodiments, the inhibition of CFU-mega is independent of the reduction of JAK2 allelic load. In some embodiments, the individual is resistant or intolerant to prior therapy without telomerase inhibitors. In some embodiments, the individual is a human.

In another aspect, provided herein are methods for reducing the proliferation of neoplastic progenitor cells in an individual diagnosed with or suspected of having myeloproliferative neoplasm or myelodysplastic syndrome, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor reduces bone marrow fibrosis in the individual. In another aspect, provided herein are methods in patients with MF to maintain platelet counts of greater than about 100 x 10 /L in the blood of the individual, the method comprising administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor increases the platelet count. In another aspect, provided herein are methods in patients with MF to maintain a hemoglobin level of at least 90 g/L, or 100 g/L or 110 g/L or 120 g/L, the method comprising administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor increases hemoglobin levels. In another aspect, provided herein are methods in patients with MF to maintain an absolute neutrophil count of at least 1.0 x 109 /L or at least 2.0 x 109 /L, the method comprising administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor increases neutrophil counts. In some aspects, the telomerase inhibitor is administered no more than once every two weeks. In other aspects, the telomerase inhibitor is administered to maintain blood platelet counts of between about 150 x 10 /μl to about 400 x 10 /μl in the blood of an individual. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGT-TAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg.

Accordingly, in one aspect, provided herein are methods for alleviating at least one symptom associated with acute myeloid leukemia in an individual in need thereof, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor alleviates at least one symptom associated with acute myeloid leukemia. In some embodiments, the symptoms comprise splenomegaly and splenic pain, early satiety, anemia, bone pain, tiredness, fever, night sweats, weight loss, weakness, fainting, nosebleeds, bruising, bleeding from the mouth or gums, melena, or stroke. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments of the present invention, the oligonucleotide comprises at least one N3'^-P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments of the present invention, the oligonucleotide comprises N3'^-P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is from 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In some embodiments, the individual carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits CFU-mega. In some embodiments, the inhibition of CFU-mega is independent of the reduction of JAK2 allelic load. In some embodiments, the individual is resistant or intolerant to prior therapy without telomerase inhibitors. In some embodiments, the individual is a human.

Accordingly, in one aspect, provided herein are methods of alleviating at least one symptom associated with myelodysplastic syndrome, such as, for example, refractory anemia, refractory anemia with excessive blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia in an individual in need thereof, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor alleviates at least one symptom associated with myelodysplastic syndrome. In some embodiments, the symptoms comprise dyspnea, fatigue, weakness, fainting, nosebleeds, bruising, bleeding from the mouth or gums, melena, petechiae, or stroke. In some embodiments of any of the present embodiments, the telomerase inhibitor comprises an oligonucleotide. In some embodiments, the oligonucleotide is complementary to the RNA component of telomerase. In some embodiments, the oligonucleotide is 10-20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In some embodiments of any of the embodiments herein, the oligonucleotide comprises at least one N3'^-P5' thiophosphoramidate internucleoside linkage. In some embodiments of any of the embodiments herein, the oligonucleotide comprises N3'^-P5' thiophosphoramidate internucleoside linkages. In some embodiments of any of the embodiments herein, the oligonucleotide further comprises a lipid moiety attached to the 5' and/or 3' end of the oligonucleotide. In some embodiments of any of the embodiments herein, the lipid moiety is attached to the 5' and/or 3' end of the oligonucleotide via a linker. In some embodiments, the linker is a glycerol or aminoglycerol linker. In some embodiments of any of the embodiments herein, the lipid moiety is a palmitoyl (C16) moiety. In some embodiments of any of the embodiments herein, the telomerase inhibitor is imetelstat. In some embodiments of any of the embodiments herein, the telomerase inhibitor is administered with a pharmaceutically acceptable excipient. In some embodiments of any of the embodiments herein, the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation, or intraocular administration. In some embodiments of any of the embodiments herein, administering the therapeutically effective amount of the telomerase inhibitor comprises contacting one or more neoplastic progenitor cells with the telomerase inhibitor. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In some embodiments of any of the embodiments herein, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments of any of the embodiments herein, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments, the individual is resistant or intolerant to prior therapy without telomerase inhibitors. In some embodiments, the individual is a human.

DESCRIPTION OF THE DRAWINGS

Figures 1A and 1B depict the effect of imetelstat on megakaryocyte growth and differentiation.

Figure 2 shows the dose response curves of megakaryocytes from colony forming units (CFU-mega).

Figure 3 shows the results for the primary study endpoint (hematologic response) from the phase II study to evaluate the activity of imetelstat (GRN163L) in patients with essential thrombocythemia requiring cytoreduction and who have failed or are intolerant to prior therapy, or who refuse standard therapy (Phase II TE imetelstat study). CR, complete response; PR, partial response. Time to first appearance of platelet count <400 x 103/μl is represented by diamond shapes, while time to complete response is indicated by circles.

Figures 4A and 4B depict results from the Phase II TE imetelstat study for the study’s secondary endpoint (JAK2 V617F allele burden). PR, partial response. Figure 4A depicts the percentage of JAK2 V617F allele burden as a function of time in months from baseline. Figure 4B depicts the median allele burden (%) as a function of time from baseline.

Figure 5 shows the results of the Phase II TE imetelstat study for the exploratory endpoint (CFU-mega).

Figure 6 represents the percentage of cell growth in culture after in vitro treatment with imetelstat of CD34+ cells obtained from a healthy donor and CD34+ cells from a patient with AML on day 5, day 7 and day 9.

Figure 7 depicts the effects of imetelstat on megakaryocyte growth and differentiation in a patient with primary myelofibrosis.

DETAILED DESCRIPTION OF THE INVENTION

The disclosure that is not part of the invention provides, inter alia, methods for reducing the proliferation of neoplastic progenitor cells and alleviating symptoms in individuals. The disclosure that is not part of the invention provided herein discloses, inter alia, methods of using telomerase inhibitor compounds to treat and alleviate symptoms associated with myeloproliferative neoplasms (MPN), such as essential thrombocythemia (ET), polycythemia vera, and myelofibrosis by targeting the neoplastic progenitor cells characteristic of these diseases. The disclosure provided herein also discloses, among others, methods of using telomerase inhibitor compounds to treat and alleviate symptoms associated with myelodysplastic syndromes (MDS) such as, for example, refractory anemia, refractory anemia with excessive blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia by targeting the neoplastic progenitor cells responsible for producing the abnormally high number of cells characteristic of these diseases. The inventors have made the surprising discovery that telomerase inhibitors (such as imetelstat) can effectively reduce circulating blood platelet levels in individuals with MPN and MDS. Furthermore, this reduction in platelet levels is seen independently of the common ET-associated mutation in the Janus kinase 2 gene (JAK2; seen in approximately 50% of ET cases) and is effective in individuals who were previously resistant to hydroxyurea treatment, which is a common state-of-the-art treatment for ET. Also provided herein are methods of using telomerase inhibitors (e.g., imetelstat) to maintain blood platelet counts in relatively normal ranges in the blood of individuals diagnosed with or suspected of having ET. Without being limited by theory, and unlike other common treatments for MPN and MDS, the telomerase inhibitor compounds used in the methods of the present disclosure appear to specifically inhibit the neoplastic progenitor cells that drive the malignancy responsible for this condition.

I. General techniques

The practice of the invention will employ, unless otherwise indicated, conventional techniques in nucleic acid chemistry, molecular biology, microbiology, cell biology, biochemistry and immunology, which are well known to those skilled in the art. Such techniques are fully explained in the literature, such as Molecular Cloning: A Laboratory Manual, second edition (Sambrook et al., 1989) and Molecular Cloning: A Laboratory Manual, third edition (Sambrook and Russel, 2001), (hereinafter referred to as "Sambrook"); Current Protocols in Molecular Biology (F.M. Ausubel et al., eds., 1987, including the 2001 supplements); PCR: The Polymerase Chain Reaction, (Mullis et al., eds., 1994). Nucleic acids can be synthesized in vitro by well-known chemical synthesis techniques, as described in, e.g., e.g., Carruthers (1982) Cold Spring Harbor Symp. Quant. Biol. 47:411-418; Adams (1983) J. Am. Chem. Soc. 105:661; Belousov (1997) Nucleic Acids Res. 525:3440-3444; Frenkel (1995) Free Radic. Biol. Med. 19:373-380; Blommers (1994) Biochemistry 33:7886-7896; Narang (1979) Meth. Enzymol. 68:90; Brown (1979) Meth. Enzymol. 68:109; Beaucage (1981) Tetra. Lett. 22:1859; Komberg and Baker, DNA Replication, 2nd Ed. (Freeman, San Francisco, 1992); Scheit, Nucleotide Analogs (John Wiley, New York, 1980); Uhlmann and Peyman, Chemical Reviews, 90:543-584, 1990.

II. Definitions

The term "nucleoside" refers to a moiety having the general structure depicted below, where B represents a nucleobase and the 2' carbon may be substituted as described below. When incorporated into an oligomer or polymer, the 3' carbon is additionally attached to an oxygen or nitrogen atom.

This structure includes 2'-deoxy and 2'-hydroxyl forms (i.e., deoxyribose and ribose) and analogs. Less commonly, a 5'-NH group may be substituted for the 5'-oxygen. "Analogs," in reference to nucleosides, include synthetic nucleosides having modified nucleobase moieties (see definition of "nucleobase" below) and/or modified sugar moieties, such as 2'-fluoro sugars, and other analogs. Such analogs are typically designed to affect binding properties, e.g., stability, specificity, or the like. The term nucleoside includes naturally occurring nucleosides, including 2'-deoxy and 2'-hydroxyl forms, e.g., as described in Komberg and Baker, DNA Replication, 2nd Ed. (Freeman, San Francisco, 1992), and analogs. "Analogs" in reference to nucleosides includes synthetic nucleosides having modified nucleobase moieties (see definition of "nucleobase" below) and/or modified sugar moieties, for example, as generally described by Scheit, Nucleotide Analogs (John Wiley, New York, 1980). Such analogs include synthetic nucleosides designed to improve binding properties, for example, stability, specificity, or the like, as described by Uhlmann and Peyman, Chemical Reviews 90:543-584, 1990). An oligonucleotide containing such nucleosides, and which typically contains synthetic nuclease-resistant internucleoside linkages, may itself be referred to as an "analog."

A "polynucleotide" or "oligonucleotide" refers to a ribose and/or deoxyribose nucleoside subunit polymer or oligomer having from about 2 to about 200 contiguous subunits. Nucleoside subunits can be linked by a variety of intersubunit linkages, including but not limited to phosphodiester, phosphotriester, methylphosphonate, P3'^N 5' phosphoramidate, N 3'^P5' phosphoramidate, N 3'^P5' thiophosphoramidate, and phosphorothioate linkages. The term also includes such polymers or oligomers having modifications, known to one of skill in the art, to the sugar (e.g., 2' substitutions), the base (see definition of "nucleoside" above), and the 3' and 5' termini. In embodiments where the oligonucleotide moiety includes a plurality of inter-subunit linkages, each linkage may be formed using the same chemistry, or a mixture of linking chemistries may be used. When an oligonucleotide is represented by a sequence of letters, such as "ATGUCCTG", it will be understood that the nucleotides are in 5'^3' order from left to right. Representation of the base sequence of the oligonucleotide in this manner does not imply the use of any particular type of internucleoside subunit in the oligonucleotide.

A "nucleobase" includes (i) native DNA and RNA nucleobases (uracil, thymine, adenine, guanine, and cytosine), (ii) modified nucleobases or nucleobase analogs (e.g., 5-methylcytosine, 5-bromouracil, or inosine), and (iii) nucleobase analogs. A nucleobase analog is a compound whose molecular structure mimics that of a typical DNA or RNA base.

The term "lipid" is used broadly herein to encompass substances that are soluble in organic solvents, but sparingly soluble, if at all, in water. The term lipid includes, but is not limited to, hydrocarbons, oils, fats (such as fatty acids and glycerides), sterols, steroids, and derivative forms of these compounds. In some embodiments, lipids are fatty acids and their derivatives, hydrocarbons and their derivatives, and sterols, such as cholesterol. Fatty acids generally contain even numbers of carbon atoms in a linear chain (typically 12 to 24 carbons) and may be saturated or unsaturated, and may contain or be modified to contain a variety of substituent groups. For simplicity, the term "fatty acid" also encompasses derivatives of fatty acids, such as fats or esters. In some embodiments, the term "lipid" also includes amphipathic compounds that contain both lipid and hydrophilic moieties.

A "telomerase inhibitor" is a compound that is capable of reducing or inhibiting the activity of the telomerase reverse transcriptase enzyme in a mammalian cell. Such an inhibitor may be a traditional drug, as described herein, or a model hTR inhibitor that includes an oligonucleotide, as described herein. In one aspect, the telomerase inhibitor is imetelstat or imetelstat sodium. In another aspect, the telomerase inhibitor is GRN163L.

A "model hTR inhibitor" is a compound that blocks the model region of the RNA component of human telomerase, thereby inhibiting the activity of the enzyme. The inhibitor is typically an oligonucleotide capable of hybridizing to this region. In some embodiments, the oligonucleotide includes a sequence effective to hybridize to a more specific portion of this region, having the sequence 5'-CUAACCCUAAC-3'.

A compound is said to "inhibit cell proliferation" if the proliferation of cells in the presence of the compound is less than that observed in the absence of the compound. That is, the proliferation of the cells is slowed or stopped in the presence of the compound. Inhibition of cancer cell proliferation may be evidenced, for example, by a reduction in cell number or rate of cell expansion, a reduction in tumor mass or rate of tumor growth, or an increase in the survival rate of a subject being treated.

An oligonucleotide having "nuclease-resistant linkages" refers to one whose backbone has subunit linkages that are substantially resistant to nuclease cleavage, in unhybridized or hybridized form, by common extracellular and intracellular nucleases in the body; that is, the oligonucleotide exhibits little or no nuclease cleavage under normal nuclease conditions in the body to which the oligonucleotide is exposed. The N 3'^P5' phosphoramidate (NP) or N 3'^P5' thiophosphoramidate (NPS) linkages described below are nuclease resistant.

An "individual" may be a mammal, such as any common laboratory model organism. Mammals include, but are not limited to, human and non-human primates, farm animals, sporting animals, pets, mice, rats, and other rodents. In some embodiments, an individual is a human.

An "effective amount" or "therapeutically effective amount" or "clinically effective amount" refers to an amount of therapeutic compound, such as telomerase inhibitor, administered to a mammalian subject, either as a single dose or as part of a series of doses, that is effective to produce a desired therapeutic effect.

As used herein, "neoplastic cells" refer to cells that exhibit relatively autonomous growth, such that they exhibit an aberrant growth phenotype characterized by a significant loss of control of cell proliferation. Neoplastic cells comprise cells that may be actively replicating or in a temporary non-replicative quiescent state (G<i>o G<o>); similarly, neoplastic cells may comprise cells that have a well-differentiated phenotype, a poorly differentiated phenotype, or a mixture of both cell types. Thus, not all neoplastic cells are necessarily replicating cells at any given time. "Neoplastic cells" encompass cells in benign neoplasms and cells in malignant neoplasms.

As used herein, "neoplastic progenitor cells" refers to cells of a cellular composition that possess the ability to become neoplastic.

As used herein, the term "neoplasia" or "neoplastic" refers to the abnormal growth of new cells. Unlike hyperplasia, neoplastic proliferation persists even in the absence of an original stimulus.

As used herein, the singular forms "a", "an" and "he/she" include plural references unless otherwise indicated.

Aspects and embodiments of the invention described herein are understood to include "comprising," "consisting," and "consisting essentially of" aspects and embodiments.

Each maximum numerical limitation given throughout this specification is intended to include all lower numerical limitations, as if such lower numerical limitations were expressly written herein. Each minimum numerical limitation given throughout this specification shall include each higher numerical limitation, as if such higher numerical limitations were expressly written herein. Each numerical range given throughout this specification shall include each narrower numerical range that falls within a wider numerical range, as if all narrower numerical ranges were expressly written herein.

III. Telomerase inhibitor compounds

Telomerase is a ribonucleoprotein that catalyzes the addition of telomeric repeat sequences (having the sequence 5'-TTAGGG-3' in humans) to chromosome ends. See, e.g., Blackburn, 1992, Ann. Rev. Biochem. 61:113-129. The enzyme is expressed in most cancer cells but not in mature somatic cells. Loss of telomeric DNA may play a role in triggering cellular senescence; see Harley, 1991, Mutation Research 256:271-282. A variety of cancer cells have been shown to be telomerase positive, including cancer cells of the skin, connective tissue, adipose tissue, breast, lung, stomach, pancreas, ovary, cervix, uterus, kidney, bladder, colon, prostate, central nervous system (CNS), retina, and hematologic tumors (such as myeloma, leukemia, and lymphoma). Telomerase targeting may be effective by providing treatments that highly discriminate between malignant and normal cells, thereby avoiding many of the harmful side effects that can accompany chemotherapy regimens that indiscriminately target dividing cells.

Telomerase inhibitors identified to date include oligonucleotides (e.g., oligonucleotides that have nuclease-resistant linkages) as well as traditional drugs. More information on telomerase inhibitor compounds can be found in U.S. Patent No. 7,998,938.

A.Traditional drugs

Telomerase inhibitors based on traditional drugs include, for example, BRACO19 ((9-(4-(N,N-dimethylamino)phenylamino)-3,6-bis(3-pyrrolodinopropionamido)acridine (see Mol. Pharmacol. 61(5):1154–62, 2002); DODC (diethyloxadicarbocyanine), and telomestatin. These compounds can act as G-quad stabilizers, promoting the formation of an inactive G-quad configuration in the RNA component of telomerase. Other telomerase inhibitors based on traditional drugs include BIBR1532 (2-[(E)-3-naphthen-2-yl but-2-enoylamino] benzoic acid) (see Ward & Autexier, Mol. Pharmacol. 68:779–786, 2005; and J. Biol. chem. 277(18):15566-72, 2002); AZT and other nucleoside analogues, such as ddG and ara-G (see, for example, U.S. Patent Nos. 5,695,932 and 6,368,789), and certain thiopyridine, benzo[b]thiophene, and pyrido[b]thiophene derivatives, described by Gaeta et al. in U.S. Patent Nos. 5,767,278, 5,770,613, 5,863,936, 5,656,638, and 5,760,062. Another example is 3-<chlorobenzo[b]thiophene-2-carboxy-2'-[(2,5-dichlorophenylamino)thia]hydrazine, described in U.S. Patent No. u>U.< 5,760,062.>

B. Oligonucleotide-based telomerase inhibitors Sequence and composition

The genes encoding the protein and RNA components of human telomerase have been cloned and sequenced (see U.S. Patent Nos. 6,261,836 and 5,583,016, respectively). Oligonucleotides can be directed against the mRNA encoding the protein component of telomerase (the human form of which is known as human telomerase reverse transcriptase, or hTERT) or the RNA component of the telomerase holoenzyme (the human form of which is known as human telomerase RNA, or hTR).

The nucleotide sequence of the RNA component of human telomerase (hTR) is shown in the sequence listing below (SEQ ID NO: 1), in the 5'43' direction. The sequence is shown using standard abbreviations for ribonucleotides; those skilled in the art will recognize that the sequence also represents the sequence of cDNA, in which ribonucleotides are replaced by deoxyribonucleotides, with uridine (U) replaced by thymidine (T). The template sequence of the RNA component is located within the region defined by nucleotides 46-56 (5'-CUAACCCUAAC-3'), which is complementary to a telomeric sequence composed of approximately one and two-thirds telomeric repeat units. The template region functions to specify the sequence of telomeric repeats that telomerase adds to chromosome ends and is essential for telomerase enzyme activity (see, e.g., Chenet al., Cell 100: 503-514, 2000; Kim et al., Proc. Natl. Acad. Sci. USA 98 (14):7982-7987, 2001). The design of antisense, ribozyme, or small interfering RNAs (siRNAs) to inhibit or cause the destruction of mRNAs is well known (see, e.g., Lebedeva, I, et al. Annual Review of

Pharmacology and Toxicology, Vol. 41: 403-419, April 2001; Macejak, D, et al., Journal of Virology, Vol. 73 (9): 7745-7751, September 1999, and Zeng, Y. et al., PNAS Vol. 100 (17) p. 9779-9784, Aug. 19, 2003) and such agents can be designed to target hTERT mRNA and thereby inhibit hTERT protein production in a target cell, such as a cancer cell (see, e.g., U.S. Patent Nos. 6,444,650 and 6,331,399).

Oligonucleotides that target hTR (i.e., the RNA component of the enzyme) act as inhibitors of telomerase enzyme activity by blocking or otherwise interfering with the interaction of hTR with the hTERT protein, which interaction is necessary for telomerase function (see, e.g., Villeponteau et al., U.S. Patent No. 6,548,298).

A preferred hTR target region is the template region, spanning nucleotides 30-67 of SEQ ID NO:1 (GGGUUGCGGAGGGUGGGCCUGGGAGGGGUGGUGGCCAUUUUUUGUCUAACCCUAACUGAGAAGGGCGUA GCGCCGUGCUUUUGCUCCCCGCGCGCUGUUUUUCUCGCUGACUUUCAGCGGGCGGAAAAGCCUCGGCCUG CCGCCUUCCACCGUUCAUUCUAGAGCAAACAAAAA AUGUCAGCUGCUGGCCCGUUCGCCUCCCGGGGACCU GCGGCGGGUCGCCUGCCCAGCCCCCGAACCCCGCCUGGAGCCGCGGUCGGCCCGGGGCUUCUCCGGAGGC ACCCACUGCCACCGCGAAGAGUUGGGCUCUGUCAGCCGCGGGUCUCUCGGGGGCGAGGGCGAGGUUCACC GUUUCAGGCCGCAGGAAGAGGAACGGAGCGAGUCCCGCCGCGGCGCGAUUCCCUGAGCUGUGGGACGUGC ACCCAGGACUCGGCUCACACAUGCAGUUCGCUUUCCUGUUGGUGGGGGGAACGCCGAUCGUGCGCAUCCGU CACCCCUCGCCGGCAGUGGGGGCUUGUGAACCCCCAAACCUGACUGACUGGGCCAGUGUGCU). Oligonucleotides that target this region are referred to herein as "hTR template inhibitors" (see, e.g., Herbert et al., Oncogene 21(4):638–42 (2002).) Preferably, said oligonucleotide includes a sequence that is complementary or nearly complementary to some portion of the 11 nucleotide region having the sequence 5'-CUAACCCUAAC-3'(SEQ ID NO: 23).

Another preferred target region is the region spanning nucleotides 137-179 of hTR (see Pruzan et al., Nucl. Acids Research, 30:559-568, 2002). Within this region, the sequence spanning 141-153 is a preferred target. PCT publication WO 98/28442 describes the use of oligonucleotides of at least 7 nucleotides in length to inhibit telomerase, where the oligonucleotides are designed to be complementary to accessible portions of the hTR sequence outside of the template region, including nucleotides 137-196, 290-319, and 350-380 of hTR. The preferred hTR target sequence is provided below, and is identified by SEQ ID NOS: 2-22.

The region of the therapeutic oligonucleotide that targets the hTR sequence is preferably exactly complementary to the corresponding hTR sequence. While mismatches can be tolerated in certain instances, they are expected to decrease the specificity and activity of the resulting oligonucleotide conjugate. In particular embodiments, the base sequence of the oligonucleotide is thus selected to include a sequence of at least 5 nucleotides exactly complementary to the hTR target, and enhanced telomerase inhibition can be obtained if increasing lengths of complementary sequence are employed, such as at least 8, at least 10, at least 12, at least 13, or at least 15 nucleotides exactly complementary to the hTR target. In other embodiments, the oligonucleotide sequence includes a sequence of at least 5 to 20, at least 8 to 20, at least 10 to 20, or at least 10 to 15 nucleotides exactly complementary to the hTR target sequence.

Optimal telomerase inhibitory activity can be obtained when the full length of the oligonucleotide is selected to be complementary to the hTR target sequence. However, the full length of the oligonucleotide need not be exactly complementary to the target sequence, and the oligonucleotide sequence may include regions that are not complementary to the target sequence. Such regions may be added, for example, to confer other properties to the compound, such as sequences that facilitate purification. Alternatively, an oligonucleotide may include multiple repeats of a sequence complementary to an hTR target sequence.

If the oligonucleotide is to include regions that are not complementary to the target sequence, such regions are typically positioned at one or both of the 5' or 3' ends. Exemplary sequences targeting human telomerase (hTR) RNA include the following:

ta u s s I t a ü u s u 41 - Í4 12

CActtAQGcrrMi U - K11

<T A JC K Ü 'JT JhU A C A>12 SJ 14

7AQW77ACAC4 ) >5315

GITMJTOTrW? 4 Í - 5 Í 1$

o i r u n m c n r Íi -S - Í17

The internucleosidic linkages in the oligonucleotide may include any of the available oligonucleotide chemistries, e.g., phosphodiester, phosphotriester, methylphosphonate, P3'^N 5' phosphoramidate, N 3'^P5' phosphoramidate, N 3'^P5' thiophosphoramidate, and phosphorothioate. Typically, but not necessarily, all internucleosidic linkages within the oligonucleotide will be of the same type, although the oligonucleotide component may be synthesized using a mixture of different linkages.

In some embodiments, the oligonucleotide has at least one N-3'^P5' phosphoramidate (NP) or N-3'^P5' thiophosphoramidate (NPS) linkage, which linkage may be represented by the structure: 3'-(-NH--P(=O)(--XR)--O-)-5', where X is O or S and R is selected from the group consisting of hydrogen, alkyl, and aryl; and pharmaceutically acceptable salts thereof, when XR is OH or S. In other embodiments, the oligonucleotide includes all NP linkages or, in some embodiments, all NPS linkages.

In one embodiment, the sequence for an hTR template inhibitor oligonucleotide is the sequence complementary to nucleotides 42-54 of SEQ ID NO: 1 above. The oligonucleotide having this sequence (TAGGGTTAGACAA; SEQ ID NO:12) and 3'^P5' N-thiophosphoramidate (NPS) linkages is designated herein as GRN163. See, for example, Asai et al., Cancer Research 63:3931-3939 (2003) and Gryaznov et al., Nucleosides Nucleotides Nucleic Acids 22(5-8):577-81 (2003).

Oligonucleotide GRN163 administered alone has shown inhibitory activity in vitro in cell culture, including cancer cells of squamous cell carcinoma, breast epithelium, renal carcinoma, renal adenocarcinoma, pancreas, brain, colon, prostate, leukemia, lymphoma, myeloma, epidermis, cervix, ovary and liver.

Oligonucleotide GRN163 has also been tested and shown to be therapeutically effective in a variety of animal tumor models, including ovarian and lung, both small cell and non-small cell (see, e.g., U.S. Patent No. 7,998,938).

C.Lipid-oligonucleotide conjugates

In some embodiments, the oligonucleotide-based telomerase inhibitors disclosed herein include at least one covalently attached lipid group (see U.S. Publication No. 2005/0113325). This modification provides superior cellular uptake properties such that an equivalent biological effect can be obtained using smaller amounts of the conjugated oligonucleotide compared to the unmodified form. When applied to the human therapeutic setting, this may translate into lower risks of toxicity and cost savings.

The lipid group L is typically an aliphatic hydrocarbon or fatty acid, including derivatives of hydrocarbons and fatty acids, with examples being straight chain saturated compounds having 14-20 carbons, such as myristic (tetradecanoic) acid, palmitic (hexadecanoic) acid and stearic (octadeacanoic) acid, and their corresponding aliphatic hydrocarbon forms, tetradecane, hexadecane and octadecane. Examples of other suitable lipid groups that may be employed are sterols, such as cholesterol, and substituted fatty acids and hydrocarbons, particularly the polyfluorinated forms of these groups. The scope of the lipid group L includes derivatives such as amine, amide, ester and carbamate derivatives. The type of derivative is often determined by the mode of linkage to the oligonucleotide, as exemplified below:

when -R is -(CH2)-|4CH3 (palmitoyl). This compound is designated here as GRN163L (imetelstat).

In one exemplary structure, the lipid moiety is palmitoylamide (derived from palmitic acid), conjugated through an aminoglycerol linker to the 5' thiophosphate group of an NPS-linked oligonucleotide. The NPS oligonucleotide having the sequence shown for GRN163 and conjugated in this manner (as shown below) is designated herein as GRN163L (imetelstat). In a second exemplary structure, the lipid, such as palmitoylamide, is conjugated through the 3' terminal amino group of an NPS oligonucleotide.

D. Pharmaceutical compositions

In some aspects of the present disclosure, when employed as pharmaceuticals, the telomerase inhibitor compounds disclosed herein may be formulated with a pharmaceutically acceptable excipient or carrier to be formulated into a pharmaceutical composition.

When employed as pharmaceuticals, the telomerase inhibitor compounds may be administered in the form of pharmaceutical compositions. These compounds may be administered by a variety of routes, including oral, rectal, transdermal, subcutaneous, intravenous, intramuscular, and intranasal. These compounds are effective as injectable and oral compositions. Such compositions are prepared in a manner well known in the art of pharmaceuticals and comprise at least one active compound. When employed as oral compositions, the telomerase inhibitor compounds described herein are protected from acid digestion in the stomach by a pharmaceutically acceptable protectant.

This disclosure also includes pharmaceutical compositions containing, as an active ingredient, a telomerase inhibitor compound in association with one or more pharmaceutically acceptable excipients or carriers. In making the compositions of this disclosure, the active ingredient is typically mixed with an excipient or carrier, diluted with an excipient or carrier, or included within such an excipient or carrier which may be in the form of a capsule, sachet, paper, or other container. When the excipient or carrier serves as a diluent, it may be a solid, semi-solid, or liquid material, which acts as a vehicle, carrier, or medium for the active ingredient. Thus, the compositions may be in the form of tablets, pills, powders, lozenges, sachets, wafers, elixirs, suspensions, emulsions, solutions, syrups, aerosols (as a solid or liquid medium), ointments containing, for example, up to 10% by weight of the active compound, soft and hard gelatin capsules, suppositories, sterile injectable solutions and sterile packaged powders.

When preparing a formulation, it may be necessary to grind the active lyophilized compound to provide the appropriate particle size prior to combining it with the other ingredients. If the active compound is substantially insoluble, it is typically ground to a particle size of less than 200 mesh. If the active compound is substantially water-soluble, the particle size is typically adjusted by grinding to provide a substantially uniform distribution in the formulation, e.g., about 40 mesh.

It may be convenient or desirable to prepare, purify and/or handle a corresponding salt of the active compound, for example, a pharmaceutically acceptable salt. Examples of pharmaceutically acceptable salts are set forth in Berge et al., 1977, "Pharmaceutically Acceptable Salts," J. Pharm. Sci., Vol. 66, pp. 1-19. For example, if the compound is anionic, or has a functional group that can be anionic (e.g., -COOH can be -COO-), then a salt can be formed with a suitable cation. Examples of suitable inorganic cations include, but are not limited to, Na<+>. Examples of suitable organic cations include, but are not limited to, ammonium ions (i.e., NH<4+>) and substituted ammonium ions (e.g., NH<3>R<+>, NH<2>R<2+>, NHR<3+>, NR<4+>).

Some examples of suitable excipients or carriers include lactose, dextrose, sucrose, sorbitol, mannitol, starches, gum acacia, calcium phosphate, alginates, tragacanth, gelatin, calcium silicate, microcrystalline cellulose, polyvinylpyrrolidone, cellulose, sterile water, syrup, and methylcellulose. The formulations may additionally include: lubricating substances such as talc, magnesium stearate, and mineral oil; wetting substances; emulsifying and suspending substances; preservative substances such as methyl and propyl hydroxybenzoates; sweetening substances; and flavoring substances. The compositions of the disclosure may be formulated to provide rapid, sustained, or delayed release of the active ingredient after administration to the patient employing methods known in the art.

The compositions may be formulated in unit dosage form, each dosage containing from about 5 mg to about 100 mg or more, such as any of about 1 mg to about 5 mg, 1 mg to about 10 mg, about 1 mg to about 20 mg, about 1 mg to about 30 mg, about 1 mg to about 40 mg, about 1 mg to about 50 mg, about 1 mg to about 60 mg, about 1 mg to about 70 mg, about 1 mg to about 80 mg, or about 1 mg to about 90 mg, including any range therebetween, of the active ingredient. The term "unit dosage forms" refers to physically discrete units suitable as unitary dosages for individuals, each unit containing a predetermined amount of active ingredient calculated to produce the desired therapeutic effect, in association with a suitable pharmaceutical excipient or carrier.

Telomerase inhibitor compounds are effective over a wide dosage range and are generally administered in a therapeutically effective amount. However, it will be understood that the amount of the telomerase inhibitor compounds actually administered will be determined by a physician, in light of the relevant circumstances, including the condition being treated, the route of administration chosen, the actual compound administered, the age, weight and response of the individual patient, the severity of the patient's symptoms, and the like.

To prepare solid compositions such as tablets, the principal active ingredient telomerase inhibitor compound is mixed with a pharmaceutical excipient or carrier to form a solid preformulation composition containing a homogeneous mixture of a compound of the present disclosure. When referring to these preformulation compositions as homogeneous, it is meant that the active ingredient is uniformly dispersed throughout the composition such that the composition can be readily subdivided into equally effective unit dosage forms such as tablets, pills, and capsules.

The tablets or pills of the present disclosure may be coated or compounded to provide a dosage form that offers the advantage of prolonged action and to protect the telomerase inhibitor compounds from acid hydrolysis in the stomach. For example, the tablet or pill may comprise an inner dosage component and an outer dosage component, the latter in the form of an envelope over the former. The two components may be separated by an enteric layer that serves to resist disintegration in the stomach and allows the inner component to pass intact into the duodenum or its release to be delayed. A variety of materials may be used for such enteric layers or coatings, such materials including various polymeric acids and mixtures of polymeric acids with materials such as resin, cetyl alcohol and cellulose acetate.

Liquid forms into which the novel compositions of the present disclosure may be incorporated for oral or injection administration include aqueous solutions, suitably flavored syrups, aqueous or oily suspensions and emulsions flavored with edible oils such as corn oil, cottonseed oil, sesame oil, coconut oil or peanut oil, as well as elixirs and similar pharmaceutical vehicles.

Compositions for inhalation or insufflation include solutions and suspensions in pharmaceutically acceptable aqueous or organic solvents, or mixtures thereof, and powders. The liquid or solid compositions may contain suitable pharmaceutically acceptable excipients as described above. The compositions may be administered orally or nasally for a local or systemic effect. The compositions in pharmaceutically acceptable solvents may be nebulized by the use of inert gases. The nebulized solutions may be inhaled directly from the nebulizer device or the nebulizer device may be connected to a nebulizer tent or intermittent positive pressure breathing machine. The solution, suspension or powder compositions may also be administered, orally or nasally, from devices that appropriately deliver the formulation.

IV. Disclosure procedures

The telomerase inhibitor compounds (such as in the pharmaceutical compositions) provided herein are useful for modulating disease states. In some embodiments, the cell proliferative disorder is associated with increased telomerase expression or activity or cell growth (such as neoplastic progenitor cells associated with abnormal platelet production in essential thrombocythemia (ET), or both.

In some aspects, provided herein are methods for alleviating at least one symptom associated with MPN in an individual in need thereof. In some aspects, provided herein are methods for alleviating at least one symptom associated with MDS in an individual in need thereof. Also provided herein are methods for reducing neoplastic progenitor cell proliferation in patients with MPN or MDS, as well as methods for maintaining blood platelet concentrations and/or red blood cell concentrations and/or white blood cell concentrations at normal levels in individuals diagnosed with or suspected of having MPN or MDS.

Myeloproliferative neoplasms, or MPNs, are hematologic cancers that arise from malignant hematopoietic myeloid progenitor cells in the bone marrow, such as red blood cell precursor cells, platelets, and granulocytes. The proliferation of malignant progenitor cells leads to an overproduction of any combination of white blood cells, red blood cells, and/or platelets, depending on the disease. These overproduced cells may also be abnormal, leading to additional clinical complications. There are several types of chronic myeloproliferative disorders. Included in the MPN disease spectrum are essential thrombocythemia (TE), polycythemia vera (PV), chronic myelogenous leukemia (CML), myelofibrosis (MF), chronic neutrophilic leukemia, chronic eosinophilic leukemia, and acute myelogenous leukemia (AML).

A myelodysplastic syndrome (MDS) is a group of symptoms that includes cancers of the blood and bone marrow. Myelodysplastic syndromes (MDS) include diseases such as refractory anemia, refractory anemia with excess blasts, refractory cytopenia with multilineage dysplasia, refractory cytopenia with unilineage dysplasia, and chronic myelomonocytic leukemia (CMML). Immature blood stem cells (blasts) do not develop into healthy red blood cells, white blood cells, or platelets. The blast dies in the bone marrow or shortly after traveling into the blood. This leaves less room for healthy red blood cells, white blood cells, and/or platelets to form in the bone marrow.

A. Essential thrombocythemia

The megakaryocyte is a bone marrow cell responsible for the production of blood platelets, which are necessary for normal blood clotting. Megakaryocytes normally account for 1 in 10,000 bone marrow cells, but can increase in number almost 10-fold during the course of certain diseases.

Megakaryocytes are derived from hematopoietic stem cell precursor cells in the bone marrow. Once the cell has completed differentiation and become a mature megakaryocyte, the process of platelet production begins. While many cytokines are suspected to play a role in stimulating megakaryocytes to produce platelets, it is the cytokine thrombopoietin that induces megakaryocytes to form small protoplatelet processes. Platelets are held within these inner membranes within the cytoplasm of megakaryocytes. Each of these protoplatelet processes can give rise to 2000-5000 new platelets upon rupture. In general, 2/3 of these newly produced platelets will remain in circulation, while 1/3 will be sequestered by the spleen.

Essential thrombocythemia (ET) is a chronic disorder associated with increased or abnormal production of blood platelets. Platelet formation in ET occurs independently of cytokines, and megakaryocytes produce platelets in an unregulated manner. Because platelets are involved in blood clotting, abnormal production can lead to inappropriate blood clot formation or bleeding, increasing the risk of gastrointestinal bleeding, heart attack, and stroke.

Often, many patients with ET are asymptomatic; diagnosis usually occurs after blood counts as part of a routine check-up reveal a high platelet count. When symptoms of ET are present, they may include fatigue or may be related to small or large vessel disorders or bleeding. Small vessel disorders (often considered vasomotor in nature) may result in: headache, vision disturbances or silent migraines, dizziness or lightheadedness, coldness or blueness of the fingers and toes, or burning, redness, and pain in the hands and feet (www.mpnresearchfoundation.org/Essential-Thrombo-cythemia). Thrombotic complications can be quite serious, leading to: stroke, transient ischemic attack (TIA), heart attack, deep vein thrombosis, or pulmonary embolism (blood clot in the lung). Bleeding may manifest as easy bruising, nosebleeds, heavy periods, gastrointestinal bleeding, or blood in the urine (www.mpnresearchfoundation.org/Essential-Thrombocythemia). A small minority of people with ET may later develop acute leukemia or myelofibrosis, which can be life-threatening. Acute myelogenous leukemia is a rapidly progressing type of blood and bone marrow cancer. Myelofibrosis is a progressive bone marrow disorder that results in bone marrow scarring, severe anemia, and an enlarged liver and spleen.

According to the World Health Organization, the diagnosis of ET requires that criteria A1 to A4 be met: (A1) a sustained platelet count >450 x 109/L; (A2) bone marrow showing increased numbers of mature and enlarged megakaryocytes and no marked increase in left shift of granulopoiesis or erythropoiesis; (A3) does not meet WHO criteria for polycythemia, primary myelofibrosis, chronic myeloid leukemia, myelodysplastic syndrome, or other myeloid neoplasm; and (A4) with an acquired mutation or clonal marker or no reactive cause for thrombocytosis (Swedlow, et al., (2008) WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, Lyon, IARC Press). When diagnosing TE, some clinicians use the British Committee for Standards in Haematology criteria (published in 2010), which are similar to the 2008 WHO criteria but differ in several important respects (Beer, et al., (2010) Blood 117(5): 1472-1482).

Tests that may be done to diagnose TE include: (1) blood tests to rule out other causes of a high platelet count, including tests for iron deficiency and indicators of inflammation (other blood diseases that mimic TE are also ruled out); (2) testing for JAK2 gene mutations (which occur in about 50% of cases) or MPL (which occur in up to 5% of cases); (3) bone marrow biopsies to look for classic signs of TE, including an increase in platelet precursors. More information related to the diagnosis of TE can be found in U.S. Patent Application Publication No. 2006/0166221.

TE is generally treated by the use of: modification of cardiovascular risk factors, antiplatelet therapy, and cytoreductive therapy (Beer, et al., Blood 117(5): 1472-1482; hereinafter (Beer et al., 2010). With regard to cardiovascular risk factors, patients are screened for hypertension, diabetes, smoking, hypercholesterolemia, and obesity, and treated where indicated according to appropriate guidelines for those conditions (Beer et al., 2010). Antiplatelet therapy includes, but is not limited to: aspirin unless contraindicated and antiplatelet agents such as clopidogrel. Patients with TE can be stratified based on thrombotic risk; high-risk patients are older than 60 years, have prior thrombotic events, or a platelet count greater than 1500 x 109 /L; these high-risk patients are likely to be treated with a platelet count greater than 1500 x 109 /L. benefit from cytoreductive therapy (Beer et al., 2010).

Despite a possible increased risk of leukemic transformation when patients with ET are treated with hydroxyurea, it remains the first-line therapy for most patients requiring treatment (Beer et al, 2010). Other treatments include, but are not limited to, interferon, anagrelide, pipobroman, busulfan, and radioactive phosphorus irradiation.

Current pharmacological treatment for ET is not curative and there is little evidence to suggest a favourable effect on survival. None of these current strategies directly address or target the malignant clonal cells responsible for the disease, the progression of the disease or the symptoms experienced by patients that affect quality of life. The aim of current treatment in ET is to prevent thrombohemorrhagic complications. Major progress in elucidating the pathogenesis of ET was made with the description, in 2005, of the somatic mutation JAK2 (V617F), which is present in 50-60% of patients with ET (James, et al. (2005) Nature 434: 1144-1148; Kralovics, et al. (2005) N Engl J Med 352: 1779-90; Baxter, et al. (2005) Lancet 365: 1054-61; Levine, et al. (2005) Cancer Cell 7: 387-97). In addition to the presence and allelic burden of the JAK2/V617F mutation, baseline leukocytosis has recently been recognized as a novel disease-related risk factor in ET (Ziakas PD. (2008) Haematologica 93: 1412-1414; Carobbio et al., (2007) Blood 109: 2310-2313). Evidence also indicates that leukocytosis has prognostic significance and may be considered a causative factor for vascular events (Barbui, et al., (2009) Blood 114: 759-63).

B.Polycythemia Vera

Patients with polycythemia vera (PV) have a marked increase in red blood cell production. Treatment is directed at reducing the excessive number of red blood cells. PV may develop a late phase in its course that resembles primary myelofibrosis with cytopenias and marrow hypoplasia and fibrosis. The Janus Kinase 2 (JAK2) gene mutation on chromosome 9 that causes increased proliferation and survival of hematopoietic precursors in vitro has been identified in most patients with PV. Patients with PV are at increased risk for cardiovascular and thrombotic events and transformation to acute myelogenous leukemia or primary myelofibrosis. Treatment for PV includes chronic intermittent phlebotomy to maintain the hematocrit below 45% in men and 40% in women. Other possible treatments include hydroxyurea, interferon alpha, and low-dose aspirin.

C.Myelofibrosis

Myelofibrosis or MF is a myeloproliferative neoplasm in the same disease spectrum as ET. Patients with MF often carry the JAK2 V617F mutation in their bone marrow. Occasionally, ET progresses to MF. JAK2 inhibition is currently considered a standard of care for MF in countries where ruxolitinib (Jakafi®), a janus kinase inhibitor, is approved. There is no evidence that JAK2 inhibitors, such as Jakafi®, selectively inhibit the proliferation of the leukemic clone responsible for the disease and therefore they cannot be “disease modifying”.

D. Acute myelogenous leukemia

Acute myelogenous leukemia (AML) is a cancer of the myeloid line of blood cells. AML is the most common acute leukemia affecting adults. Patients with AML have a rapid growth of abnormal white blood cells that build up in the bone marrow and interfere with the production of normal blood cells. The replacement of normal bone marrow with leukemic cells causes a drop in normal red blood cells, platelets, and white blood cells. Symptoms of AML include tiredness, shortness of breath, easy bruising and bleeding, and an increased risk of infection. As an acute leukemia, AML progresses rapidly and is usually fatal within weeks to months if left untreated. The standard of care for AML is chemotherapy treatment aimed at inducing a remission; patients may receive a hematopoietic stem cell transplant.

E.Myelodysplastic syndrome

Myelodysplastic syndrome (MDS) is a group of symptoms that includes cancer of the blood and bone marrow. Immature blood stem cells (blasts) do not develop into healthy red blood cells, white blood cells, or platelets. The blast dies in the bone marrow or shortly after traveling into the blood. This leaves less room for healthy red blood cells, white blood cells, and/or platelets to form in the bone marrow.

Myelodysplastic syndromes (MDS) are a collection of hematologic medical conditions that involve ineffective production of the myeloid class of blood cells. Patients with MDS often develop severe anemia and require frequent blood transfusions. In some embodiments, the disease worsens and the patient develops cytopenias (low blood counts) caused by progressive bone marrow failure. In some embodiments, the disease transforms into acute myelogenous leukemia (AML). If the overall percentage of bone marrow myeloblasts increases over a particular threshold (20% for WHO and 30% for FAB), then transformation to acute myelogenous leukemia (AML) is said to occur.

F. Procedures for treating MPN or MDS using telomerase inhibitors

Provided herein are methods for reducing the proliferation of neoplastic progenitor cells and alleviating associated symptoms in individuals diagnosed with or believed to have MPN or MDS by the administration of telomerase inhibitors (such as any of the telomerase inhibitors described herein).

Procedures may be performed in an adjuvant setting. "Adjuvant setting" refers to a clinical setting in which an individual has had a history of proliferative disease and has generally (but not necessarily) responded to therapy, including but not limited to surgery (such as surgical resection), radiation therapy, and chemotherapy. However, because of their history of proliferative disease, these individuals are considered at risk for developing the disease. Treatment or administration in the "adjuvant setting" refers to a later mode of treatment. The degree of risk (i.e., when an individual in the adjuvant setting is considered "high risk" or "low risk") depends on several factors, usually the extent of the disease when first treated.

The procedures provided herein may also be practiced in a "neoadjuvant setting," i.e., the procedure may be performed prior to primary/definitive treatment. In some embodiments, the individual has been previously treated. In some embodiments, the individual has not been previously treated. In some embodiments, the treatment is a first-line treatment.

1. Procedures to relieve symptoms of myeloproliferative neoplasms and myelodysplastic syndromes

In some aspects, the present disclosure is directed to methods of inhibiting the symptoms or conditions (disabilities, impairments) associated with myeloproliferative neoplasms as described in detail above. As such, it is not required that all effects of the condition be completely prevented or reversed, although the effects of the presently disclosed methods are likely to extend to a significant therapeutic benefit for the patient. As such, a therapeutic benefit is not necessarily a complete prevention or cure for a particular condition resulting from the myeloproliferative neoplasm, but may encompass an outcome that includes reducing or preventing symptoms resulting from a cell proliferative disorder, reducing or preventing the occurrence of such symptoms (either quantitatively or qualitatively), reducing the severity of such symptoms or their physiological effects, and/or improving the recovery of the individual after experiencing symptoms of myeloproliferative neoplasm.

In some aspects, the present disclosure is directed to methods of inhibiting the symptoms or conditions (disabilities, impairments) associated with myelodysplastic syndrome (MDS) as described in detail above. As such, not all effects of the condition are required to be completely prevented or reversed, although the effects of the presently described methods are likely to extend to a significant therapeutic benefit for the patient. As such, a therapeutic benefit is not necessarily a complete prevention or cure for a particular condition resulting from myelodysplastic syndrome, but may encompass an outcome that includes reducing or preventing symptoms resulting from a cell proliferative disorder, reducing or preventing the occurrence of such symptoms (either quantitatively or qualitatively), reducing the severity of such symptoms or their physiological effects, and/or improving the recovery of the individual after experiencing symptoms of myelodysplastic syndrome.

As used herein, the phrase "alleviating at least one symptom associated with" a disorder, disease, or condition (such as MPN or MDS) denotes reversing, inhibiting the progress of, or preventing the disorder or condition to which such term applies, or reversing, inhibiting the progress of, or preventing one or more symptoms of the disorder or condition to which such term applies. Specifically, a composition of the present disclosure (such as any of the telomerase inhibitor compounds disclosed herein), when administered to an individual, can treat or prevent one or more of the symptoms or conditions associated with MPN or MDS and/or reduce or alleviate symptoms or conditions associated with this disorder. As such, protecting an individual against the effects or symptoms resulting from MPN or MDS includes both preventing or reducing the occurrence and/or severity of the effects of the disorder and treating a patient in whom the effects of the disorder are already occurring or beginning to occur. A beneficial effect can be readily assessed by one of skill in the art and/or a trained physician treating the patient. Preferably, there is a positive or beneficial difference in the severity or occurrence of at least one clinical or biological score, value or measure used to evaluate said patients in those who have been treated with the methods of the present disclosure compared to those who have not been.

Accordingly, in some aspects, provided herein are methods for alleviating at least one symptom associated with MPN or MDS in an individual in need thereof, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administering the telomerase inhibitor alleviates at least one symptom associated with MPN or MDS. In some embodiments, the symptom comprises headache, dizziness or lightheadedness, chest pain, weakness, fainting, vision changes, numbness or tingling in the extremities, redness, stabbing or burning pain in the extremities (erythromelalgia), splenomegaly, nosebleeds, bruising, bleeding from the mouth or gums, melena, heart attack (myocardial infarction), or stroke. In some embodiments, the telomerase inhibitor comprises an oligonucleotide that may be complementary to the RNA component of telomerase and in some cases may be between 10 and 20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In other embodiments, the oligonucleotide comprises N3'AP5' thiophosphoramidate internucleoside linkages. The oligonucleotide may also be conjugated to a lipid moiety at its 5' or 3' end, optionally through a linker (such as a glycerol or amino glycerol linker). In some embodiments, the lipid moiety is a palmitoyl (C16) moiety. In yet another instance, the telomerase inhibitor is imetelstat. In some embodiments, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In other embodiments, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments, administration of the telomerase inhibitor inhibits CFU-mega. In still other embodiments, inhibition of CFU-mega is independent of reducing JAK2 V617F allelic load. In some embodiments, the individual may be resistant or intolerant to prior non-telomerase inhibitor therapy (including, but not limited to, hydroxyurea, anagrelide, or interferon a-2B). In another embodiment, the individual is a human.

In some aspects, the effective amount of a telomerase inhibitor administered to the patient is 7.5 mg/kg to 9.3 mg/kg. In other aspects, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In another aspect, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments described herein, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor includes at least one of 6.5 mg/kg, 6.6 mg/kg, 6.7 mg/kg, 6.8 mg/kg, 6.9 mg/kg, 7 mg/kg, 7.1 mg/kg, 7.2 mg/kg, 7.3 mg/kg, 7.4 mg/kg, 7.5 mg/kg, 7.6 mg/kg, 7.7 mg/kg, 7.8 mg/kg, 7.9 mg/kg, 8 mg/kg, 8.1 mg/kg, 8.2 mg/kg, 8.3 mg/kg, 8.4 mg/kg,

8.5 mg/kg, 8.6 mg/kg, 8.7 mg/kg, 8.8 mg/kg, 8.9 mg/kg, 9 mg/kg, 9.1 mg/kg, 9.2 mg/kg kg, 9.3 mg/kg, 9.4 mg/kg, 9.5 mg/kg, 9.6 mg/kg, 9.7 mg/kg, 9.8 mg/kg, 9.9 mg/kg, 10 mg/kg, 10.1 mg/kg, 10.2 mg/kg, 10.3 mg/kg, 10.4 mg/kg, 10.5 mg/kg, 10.6 mg/kg , 10.7 mg/kg, 10.8 mg/kg, 10.9 mg/kg, 11 mg/kg, 11.1 mg/kg, 11.2 mg/kg, 11.3 mg/kg, 11.4 mg/kg, 11.5 mg/kg, 11.6 mg/kg, 11.7 mg/kg, 11.8 mg/kg, 11.9 mg/kg, 12 mg/kg, 12.1 mg/ kg, 12.2 mg/kg, 12.3 mg/kg, 12.4 mg/kg, 12.5 mg/kg, 12.6 mg/kg, 12.7 mg/kg, 12.8 mg/kg , 12.9 mg/kg, or 13 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor administered to the individual is not 9.4 mg/kg.

In some aspects, the individual diagnosed with or believed to have MPN carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. Methods for determining whether an individual carries this mutation, as well as for determining the allelic burden, are many and well known in the art (see, e.g., U.S. Patent Application Nos. 2009/0162849, 2007/0224598, and 2009/0162849. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual.

2. Procedures to reduce neoplastic cell proliferation

In another aspect, provided herein are methods for reducing the proliferation of neoplastic progenitor cells in an individual diagnosed with or suspected of having essential thrombocythemia, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor reduces the proliferation of neoplastic progenitor cells in the individual. In some embodiments, the telomerase inhibitor comprises an oligonucleotide that may be complementary to the RNA component of telomerase and in some cases may be between 10 and 20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In other cases, the oligonucleotide comprises N3'AP5' thiophosphoramidate internucleoside linkages. The oligonucleotide may also be conjugated to a lipid moiety at its 5' or 3' end, optionally through a linker (such as a glycerol or amino glycerol linker). In some embodiments, the lipid moiety is a palmitoyl (C16) moiety. In yet another instance, the telomerase inhibitor is imetelstat. In some embodiments, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In other instances, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments, administration of the telomerase inhibitor inhibits CFU-mega. In still other instances, inhibition of CFU-mega is independent of reduction of JAK2 V617F allelic load. In some embodiments, the individual may be resistant or intolerant to prior non-telomerase inhibitor therapy (including, but not limited to, hydroxyurea, anagrelide, or interferon a-2B). In another instance, the individual is a human.

In some aspects, the reduction of neoplastic progenitor cell proliferation results in platelet counts less than any of about 600 x 103 /μl, 575 x 103 /μl, 550 x 103 /μl, 525 x 103 /μl, 500 x 103 /μl, 475 x 103 /μl, 450 x 103 /μl, 425 x 103 /μl, 400 x 103 /μl, 375 x 103 /μl, 350 x 103 /μl x 103 /μl, 325 x 103 /μl, 300 x 103/μl, 275 x 103/μl, 250 x 103/μl, 225 x 103/μl, 200 x 103/μl, 175 x 103/pl, or 150 x 103/pl in the individual's blood, including values between these numbers. In other aspects, the reduced neoplastic cell proliferation results in a reduced platelet count (such as any of the platelet counts described above) in the individual's blood at any of about 24 weeks, 23 weeks, 22 weeks, 21 weeks, 20 weeks, 19 weeks, 18 weeks, 17 weeks, 16 weeks, 15 weeks, 14 weeks, 13 weeks, 12 weeks, 11 weeks, 10 weeks, 9 weeks, 8 weeks, 7 weeks, 6 weeks, 5 weeks, 4 weeks, 3 weeks, or 2 weeks or less after the start of administration of the telomerase inhibitor.

In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In other embodiments, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In another embodiment, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor includes at least about 6.5 mg/kg, 6.6 mg/kg, 6.7 mg/kg, 6.8 mg/kg, 6.9 mg/kg, 7 mg/kg, 7.1 mg/kg, 7.2 mg/kg, 7.3 mg/kg, 7.4 mg/kg, 7.5 mg/kg, 7.6 mg/kg, 7.7 mg/kg, 7.8 mg/kg, 7.9 mg/kg, 8 mg/kg, 8.1 mg/kg, 8.2 mg/kg, 8.3 mg/kg, 8.4 mg/kg, 8.5 mg/kg, 8.6 mg/kg, 8.7 mg/kg, 8.8 mg/kg, 8.9 mg/kg, 9 mg/kg, 9.1 mg/kg, 9.2 mg/kg, 9.3 mg/kg, 9.4 mg/kg, 9.5 mg/kg, 9.6 mg/kg, 9.7 mg/kg, 9.8 mg/kg, 9.9 mg/kg, 10 mg/kg, 10.1 mg/kg, 10.2 mg/kg, 10.3 mg/kg, 10.4 mg/kg, 10.5 mg/kg, 10.6 mg/kg, 10.7 mg/kg, 10.8 mg/kg, 10.9 mg/kg, 11 mg/kg, 11.1 mg/kg, 11.2 mg/kg, 11.3 mg/kg, 11.4 mg/kg, 11.5 mg/kg, 11.6 mg/kg, 11.7 mg/kg, 11.8 mg/kg, 11.9 mg/kg, 12 mg/kg, 12.1 mg/kg, 12.2 mg/kg, 12.3 mg/kg, 12.4 mg/kg mg/kg, 9.4 mg/kg 9.5 mg/kg, 9.6 mg/kg, 9.7 mg/kg, 9.8 mg/kg, 9.9 mg/kg, 10 mg/kg, 10.1 mg/kg, 10.2 mg/kg, 10.3 mg/kg, 10.4 mg/kg, 10.5 mg/kg, 10.6 mg/kg, 10.7 mg/kg, 10.8 mg/kg, 10.9 mg/kg, 11 mg/kg, 11.1 mg/kg, 11.2 mg/kg, 11.3 mg/kg, 11.4 mg/kg, 11.5 mg/kg, 11.6 mg/kg, 11.7 mg/kg, 11.8 mg/kg, 11.9 mg/kg, 12 mg/kg, 12.1 mg/kg, 12.2 mg/kg, 12.3 mg/kg, 12.4 mg/kg, 12.5 mg/kg, 12.6 mg/kg, 12.7 mg/kg, 12.8 mg/kg, 12.9 mg/kg, or 13 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor administered to the individual is not 9.4 mg/kg.

In some aspects, the individual diagnosed with or believed to have TE carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual.

3. Procedures to maintain normal levels of circulating platelets

In other aspects, provided herein is a method of maintaining blood platelet counts between less than about 400 x 10 /μl in the blood of an individual diagnosed with or suspected of having essential thrombocythemia, the method comprising: administering a clinically effective amount of a telomerase inhibitor to the individual, wherein administration of the telomerase inhibitor maintains the blood platelet count of less than about 400 x 10 /μl in the individual. In some embodiments, the telomerase inhibitor comprises an oligonucleotide that may be complementary to the RNA component of telomerase and in some instances may be between 10 and 20 base pairs in length. In some embodiments, the oligonucleotide comprises the sequence TAGGGTTAGACAA. In other instances, the oligonucleotide comprises N3'AP5' thiophosphoramidate internucleoside linkages. The oligonucleotide may also be conjugated to a lipid moiety at its 5' or 3' end, optionally through a linker (such as a glycerol or amino glycerol linker). In some embodiments, the lipid moiety is a palmitoyl (C16) moiety. In yet another instance, the telomerase inhibitor is imetelstat. In some embodiments, administration of the telomerase inhibitor does not inhibit cytokine-dependent megakaryocyte growth. In other instances, administration of the telomerase inhibitor inhibits cytokine-independent megakaryocyte growth. In some embodiments, administration of the telomerase inhibitor inhibits CFU-mega. In still other instances, inhibition of CFU-mega is independent of reducing JAK2 V617F allelic load. In some embodiments, the individual may be resistant or intolerant to prior non-telomerase inhibitor therapy (including, but not limited to, hydroxyurea, anagrelide, or interferon α-2B). In another embodiment, the individual is a human.

In some aspects, administration of telomerase inhibitors (such as any of the telomerase inhibitors described herein) maintains platelet counts at physiologically normal levels. In some embodiments, administration of the telomerase inhibitors maintains a platelet count less than any of about 600 x 103 /μL, 575 x 103 /μL, 550 x 103 /μL, 525 x 103 /μL, 500 x 103 /μL, 475 x 103 /μL, 450 x 103 /μL, 425 x 103 /μL, 400 x 103 /μL, 375 x 103 /μL, 350 x 103 /μL, 325 x 103 /μL, 300 x 103 /μL, 275 x 103 /μL, 250 x 103 /μL, 225 x 103 /μL, 200 x 103 /μL, 175 x 103 /μL, or 200 x 103 /μL. 103 /pl, or 150 x 103 /pl in the individual's blood, including values between these numbers. In other aspects, administration of telomerase inhibitors maintains the platelet count between about 100-400 x 103 /μl, 150-200 x 103 /μl, 150-250 x 103 /μl, 150-300 x 103 /μl, 150-350 x 103 /μl, 150-400 x 103 /μl, 200-250 x 103 /μl, 200-300 x 103 /μl, 200-350 x 103 /μl, 200-400 x 103 /μl, 250 300 x 103 /μl, 250-350 x 103 /μl, 250-400 x 103 /μl, 300-350 x 103 /pl, 300-400 x 103 /pl, or 350 to 400 x 103 /pl in the individual's blood.

In other aspects, maintaining blood platelet counts at physiologically normal levels requires administration of the telomerase inhibitor no more than once daily, every other day, every third day, every week, every 11 days, every two weeks, every three weeks, every month, every six weeks, every two months, or longer, including any time periods in between.

In some embodiments, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.3 mg/kg. In other embodiments, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In another embodiment, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor includes at least about 6.5 mg/kg, 6.6 mg/kg, 6.7 mg/kg, 6.8 mg/kg, 6.9 mg/kg, 7 mg/kg, 7.1 mg/kg, 7.2 mg/kg,

7.3 mg/kg, 7.4 mg/kg, 7.5 mg/kg, 7.6 mg/kg, 7.7 mg/kg, 7.8 mg/kg, 7.9 mg/kg, 8 mg/kg kg, 8.1 mg/kg, 8.2 mg/kg, 8.3 mg/kg, 8.4 mg/kg, 8.5 mg/kg, 8.6 mg/kg, 8.7 mg/kg, 8.8 mg/kg, 8.9 mg/kg, 9 mg/kg, 9.1 mg/kg, 9.2 mg/kg, 9.3 mg/kg, 9.4 mg/kg, 9 .5 mg/kg, 9.6 mg/kg, 9.7 mg/kg, 9.8 mg/kg, 9.9 mg/kg, 10 mg/kg, 10.1 mg/kg, 10.2 mg/kg, 10.3 mg/kg, 10.4 mg/kg, 10.5 mg/kg, 10.6 mg/kg, 10.7 mg/kg, 10.8 mg/kg, 10.9 mg/kg, 11 mg/kg, 11 .1 mg/kg, 11.2 mg/kg, 11.3 mg/kg, 11.4 mg/kg, 11.5 mg/kg, 11.6 mg/kg, 11.7 mg/kg, 11.8 mg/kg, 11.9 mg/kg, 12 mg/kg, 12.1 mg/kg, 12.2 mg/kg, 12.3 mg/kg , 12.4 mg/kg, 12.5 mg/kg, 12.6 mg/kg, 12.7 mg/kg, 12.8 mg/kg, 12.9 mg/kg, or 13 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor administered to the individual is not 9.4 mg/kg.

In some aspects, the individual diagnosed with or believed to have TE carries a V617F gain-of-function mutation in the Janus kinase 2 (JAK2) gene. In some embodiments, administration of the telomerase inhibitor decreases the percentage of JAK2 V617F allelic load in the individual.

G. Administration of telomerase inhibitors

In some embodiments, the telomerase inhibitor (such as any of the telomerase inhibitor compounds disclosed herein) is administered as an injection. The injection may comprise the compound in combination with an aqueous injectable carrier or vehicle. Non-limiting examples of suitable aqueous injectable carriers or vehicles are well known to those skilled in the art, and they, and methods for formulating the formulations, can be found in standard references such as Alfonso AR: Remington's Pharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton Pa., 1985. Suitable aqueous injectable carriers or vehicles include water, aqueous saline, aqueous dextrose solution, and the like, optionally containing dissolution enhancers, such as 10% mannitol or other sugars, 10% glycine, or other amino acids. The composition may be injected subcutaneously, intraperitoneally, or intravenously.

In some embodiments, intravenous administration is used, and may be a continuous intravenous infusion over a period of a few minutes to an hour or more, such as about fifteen minutes. The amount administered may vary widely depending on the type of telomerase inhibitor, the size of a unit dose, the type of excipients or carriers, and other factors well known to those skilled in the art. The telomerase inhibitor may comprise, for example, about 0.001% to about 10% (w/w), about 0.01% to about 1%, about 0.1% to about 0.8%, or any range therein, with the remainder comprising the excipients or carriers.

For oral administration, the telomerase inhibitor may take the form of, for example, tablets or capsules prepared by conventional means with pharmaceutically acceptable excipients or carriers such as binding substances; lubricating fillers; disintegrants; or wetting substances. Liquid preparations for oral administration may take the form of, for example, solutions, syrups or suspensions, or may be presented as a dry product for constitution with water or other suitable vehicle before use. Such liquid preparations may be prepared by conventional means with pharmaceutically acceptable additives such as suspending substances (for example, sorbitol syrup, cellulose derivatives or hydrogenated edible fats); emulsifying substances (for example, lecithin or acacia); non-aqueous vehicles (for example, almond oil, oily esters, ethyl alcohol or fractionated vegetable oils); and preservatives (for example, methyl or propyl-p-hydroxybenzoates or sorbic acid). The preparations may also contain buffer salts, flavourings and colourings, as appropriate.

In some embodiments, the telomerase inhibitor may be administered by inhalation via an aerosol or nebulizer that may include a suitable propellant such as, for example, dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide, or a combination thereof. In one non-limiting example, a dosage unit for a pressurized aerosol may be administered via a metered dose valve. In another embodiment, gelatin capsules and cartridges, for example, may be used in an inhaler and may be formulated to contain a powdered mixture of the compound with a suitable powder base, such as, for example, starch or lactose.

In some embodiments, the amount of telomerase inhibitor administered to the individual is included in any of the following ranges: about 0.5 to about 5 mg, about 5 to about 10 mg, about 10 to about 15 mg, about 15 to about 20 mg, about 20 to about 25 mg, about about 50 mg, about 25 to about 50 mg, about about 75 mg, about 50 to about 100 mg, about 75 to about 100 mg, about 100 to about 125 mg, about about 150 mg, about 150 to about 175 mg, about about 200 mg, about 200 to about 225 mg, about about 250 mg, about 250 to about 300 mg, about about 350 mg, about 350 to about 400 mg, about 400 to about 500 mg, about 500 to about 600 mg, about 600 to about 700 mg, about 700 to about 800 mg, about 800 to about 900 mg, about 900 to about 1000 mg, about 1000 to about 1200 mg, about 1500 to about 1700 mg, about 1800 to about 1900 mg, about 2000 to about 2200 mg, about 2500 to about 2500 mg, about 2500 to about 3000 mg, about 3500 to about 4000 mg, about 4000 to about 5000 mg, about 5000 to about 6000 mg, about 6000 to about 7000 mg, about 7000 to about 8000 mg, about 8000 to about 9000 mg, about 9000 to about 10000 mg, about 10000 to about about 400 mg, about 450 mg, or about 450 to about 500 mg. In some embodiments, the amount of a telomerase inhibitor in the effective amount administered to the individual (e.g., a unit dosage form) is in the range of about 5 mg to about 500 mg, such as about 30 mg to about 300 mg or about 50 mg to about 200 mg. In some embodiments, the concentration of the telomerase inhibitor administered to the individual is diluted (about 0.1 mg/mL) or concentrated (about 180 mg/mL), including for example any of about 0.1 to about 200 mg/mL, about 0.1 to about 180 mg/mL, about 0.1 to about 160 mg/mL, about 0.1 to about 140 mg/mL, about 0.1 to about 120 mg/mL, about 0.1 to about 100 mg/mL, about 0.1 to about 80 mg/mL, about 0.1 to about 60 mg/mL, about 0.1 to about 40 mg/mL, about 0.1 to about 20 mg/mL, about 0.1 to about 10 mg/mL, about 2 to about 40 mg/mL, about 4 to about 35 mg/mL, or about 5 to about 60 mg/mL. mg/ml, from about 6 to about 30 mg/ml, from about 8 to about 25 mg/ml, from about 10 to about 20 mg/ml, from about 12 to about 15 mg/ml, or any of about 0.1 mg/ml, 0.2 mg/ml, 0.3 mg/ml, 0.4 mg/ml, 0.5 mg/ml, 0.6 mg/ml, 0.7 mg/ml, 0.8 mg/ml, 0.9 mg/ml, 1 mg/ml, 1.1 mg/ml, 1.2 mg/ml, 1.3 mg/ml,

1.4 mg/ml, 1.5 mg/ml, 1.6 mg/ml, 1.7 mg/ml, 1.8 mg/ml, 1.9 mg/ml, 2 mg/ml, 2.1 mg/ml, 2.2 mg/ml, 2.3 mg/ml, 2.4 mg/ml, or 2.5 mg/ml. In some embodiments, the concentration of the telomerase inhibitor is at least about 0.1 mg/ml, 0.2 mg/ml, 0.3 mg/ml, 0.4 mg/ml, 0.5 mg/ml , 1.3 mg/ml, 1.5 mg/ml, 2 mg/ml, 3 mg/ml, 4 mg/ml, 5 mg/ml, 6 mg/ml, 7 mg/ml, 8 mg/ml, 9 mg/ml, 10 mg/ml, 11 mg/ml, 12 mg/ml, 13 mg/ml, 14 mg/ml, 15 mg/ml,

16 mg/ml, 17 mg/ml, 18 mg/ml, 19 mg/ml, 20 mg/ml, 21 mg/ml, 22 mg/ml, 23 mg/ml, 24 mg/ml, 25 mg/ml, 26 mg/ml, 27 mg/ml, 28 mg/ml, 29 mg/ml, 30 mg/ml, 31 mg/ml, 32 mg/ml, 33 mg/ml, 33.3 mg/ml, 34 mg/ml, 35 mg/ml, 36 mg/ml, 37 mg/ml, 38 mg/ml, 39 mg/ml, 40 mg/ml , 50 mg/ml, 60 mg/ml, 70 mg/ml, 80 mg/ml, 90 mg/ml, 100 mg/ml, 110 mg/ml,

120 mg/ml, 130 mg/ml, 140 mg/ml, 150 mg/ml, 160 mg/ml, 170 mg/ml, 180 mg/ml, 190 mg/ml, 200 mg/ml, 210 mg/ml,

220 mg/ml, 230 mg/ml, 240 mg/ml, or 250 mg/ml.

Exemplary effective amounts of a telomerase inhibitor administered to the individual include, but are not limited to, at least about 25 mg/m2, 30 mg/m2, 50 mg/m2, 60 mg/m2, 75 mg/m2, 80 mg/m2, 90 mg/m2, 100 mg/m2, 120 mg/m2, 125 mg/m2, 150 mg/m2, 160 mg/m2, 175 mg/m2, 180 mg/m2, 200 mg/m2, 210 mg/m2, 220 mg/m2,

250 mg/m2, 260 mg/m2, 300 mg/m2, 350 mg/m2, 400 mg/m2, 500 mg/m2, 540 mg/m2, 750 mg/m2, mg/m2. In various cases, the amount of telomerase inhibitor administered to the individual includes less than about 350 mg/m2, 300 mg/m2, 250 mg/m2, 200 mg/m2, 150 mg/m2, 120 mg/m2, 100 mg /m2, 90 mg/m2, 50 mg/m2 or 30 mg/m2 of an inhibitor of telomerase. In some embodiments, the amount of telomerase inhibitor per administration is less than about 25 mg/m2, 22 mg/m2, 20 mg/m2, 18 mg/m2, 15 mg/m2, 14 mg/m2, 13 mg/m2. m2, 12 mg/m2, 11 mg/m2, 10 mg/m2, 9 mg/m2, 8 mg/m2, 7 mg/m2, 6 mg/m2, 5 mg/m2, 4 mg/m2, 3 mg/m2, 2 mg/m2, or 1 mg/m2. In some embodiments, the effective amount of a telomerase inhibitor administered to the individual is included in any of the following ranges: from about 1 to about 5 mg/m2, from about 5 to about 10 mg/m2, from about 10 to about 25 mg/m2, from about 25 to about 50 mg/m2, from about 50 to about 75 mg/m2, from about 75 to about 100 mg/m2, from about 100 to about 125 mg/m2, from about 125 to about 150 mg/m2, from about 150 to about 175 mg/m2, from about 175 to about 200 mg/m2, from about 200 to about 225 mg/m2, from about 225 to about 250 mg/m2, from about 250 to about 300 mg/m2, approximately 300 to about 350 mg/m2 or about 350 to about 400 mg/m2. In some embodiments, the effective amount of a telomerase inhibitor administered to the individual is about 5 to about 300 mg/m2, such as about 20 at about 300 mg/m2, about 50 to about 250 mg/m2, about 100 to about 150 mg/m2, about 120 mg/m2, about 130 mg/m2, or about 140 mg/m2 to about 260 mg /m2.

In some embodiments of any of the above aspects, the effective amount of a telomerase inhibitor administered to the individual includes at least about any of 1 mg/kg, 2.5 mg/kg, 3.5 mg/kg, 5 mg/kg, 6.5 mg/kg, 7.5 mg/kg, 9.4 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg. In various embodiments, the effective amount of a telomerase inhibitor administered to the individual includes less than about 350 mg/kg, 300 mg/kg, 250 mg/kg, 200 mg/kg, 150 mg/kg, 100 mg/kg, 50 mg/kg, 30 mg/kg, 25 mg/kg, 20 mg/kg, 10 mg/kg, 7.5 mg/kg, 6.5 mg/kg, 5 mg/kg, 3.5 mg/kg, 2.5 mg/kg, or 1 mg/kg of a telomerase inhibitor. In other embodiments of any of the above aspects, the effective amount of a telomerase inhibitor administered to the individual includes at least about any of 6.5 mg/kg, 6.6 mg/kg, 6.7 mg/kg, 6.8 mg/kg, 6.9 mg/kg, 7 mg/kg, 7.1 mg/kg, 7.2 mg/kg, 7.3 mg/kg, 7.4 mg/kg, 7.5 mg/kg, 7.6 mg/kg, 7.7 mg/kg, 7.8 mg/kg, 7.9 mg/kg, 8 mg/kg, 8.1 mg/kg, 8.2 mg/kg, 8.3 mg/kg, 8.4 mg/kg, 8.5 mg/kg, 8.6 mg/kg, 8.7 mg/kg, 8.8 mg/kg, 8.9 mg/kg, 9 mg/kg, 9.1 mg/kg, 9.2 mg/kg, 9.3 mg/kg, 9.4 mg/kg 9.5 mg/kg, 9.6 mg/kg, 9.7 mg/kg, 9.8 mg/kg, 9.9 mg/kg, 10 mg/kg, 10.1 mg/kg, 10.2 mg/kg, 10.3 mg/kg, 10.4 mg/kg, 10.5 mg/kg, 10.6 mg/kg, 10.7 mg/kg, 10.8 mg/kg, 10.9 mg/kg, 11 mg/kg, 11.1 mg/kg, 11.2 mg/kg, 11.3 mg/kg, 11.4 mg/kg, 11.5 mg/kg, 11.6 mg/kg, 11.7 mg/kg, 11.8 mg/kg, 11.9 mg/kg, 12 mg/kg, 12.1 mg/kg, 12.2 mg/kg, 12.3 mg/kg, 12.4 mg/kg, 12.5 mg/kg, 12.6 mg/kg, 12.7 mg/kg, 12.8 mg/kg, 12.9 mg/kg, or 13 mg/kg. In some embodiments, the effective amount of a telomerase inhibitor administered to the individual is not 9.4 mg/kg. In other embodiments, the effective amount of a telomerase inhibitor administered to the individual is 7.5 mg/kg to 9.3 mg/kg. In another embodiment, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 11.7 mg/kg. In still other embodiments, the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. In some embodiments herein, the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. In some embodiments herein, the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg.

Exemplary dosing frequencies for pharmaceutical compositions (such as a pharmaceutical composition containing any of the telomerase inhibitors disclosed herein) include, but are not limited to, daily; every other day; twice a week; three times a week; weekly without a break; weekly, three out of four weeks; once every three weeks; once every two weeks; weekly, two out of three weeks. In some embodiments, the pharmaceutical composition is administered about once per week, once every 2 weeks, once every 3 weeks, once every 4 weeks, once every 6 weeks, or once every 8 weeks. In some embodiments, the composition is administered at least about any of 1x, 2x, 3x, 4x, 5x, 6x, or 7x (i.e., daily) a week or three times a day, twice a day. In some embodiments, the intervals between each administration are less than about 6 months, 3 months, 1 month, 20 days, 15 days, 12 days, 10 days, 9 days, 8 days, 7 days, 6 days, 5 days, 4 days, 3 days, 2 days, or 1 day. In some embodiments, the intervals between each administration are greater than about 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 8 months, or 12 months. In some embodiments, there is no break in the dosing schedule. In some embodiments, the interval between each administration is no more than about one week.

In other aspects, the pharmaceutical composition (such as a pharmaceutical composition containing any of the telomerase inhibitors described herein) is administered to maintain blood platelet counts of between about 150 x 10 /μl to 400 x 10 /μl in the blood of an individual diagnosed with or suspected of having essential thrombocythemia. Under these conditions, the intervals between each administration may be weekly, every 2 weeks, every 3 weeks, or every 4 weeks or longer. In some embodiments, the intervals for administration of the telomerase inhibitor may be decreased over time if the platelet count in the individual remains <400 x 10 /μl in the individual's blood. In some aspects, a method is provided for determining the frequency of administration of the telomerase inhibitor for the treatment of TE comprising a) measuring the platelet count in the blood of an individual by any means known in the art and b) administering the telomerase inhibitor if the platelet counts in the individual are greater than 400 x 103 /pl.

Administration of the pharmaceutical composition (such as a pharmaceutical composition containing any of the telomerase inhibitors disclosed herein) may extend over an extended period of time (such as during maintenance therapy), such as from about one month to about seven years. In some embodiments, the composition is administered for a period of at least about 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 18, 24, 30, 36, 48, 60, 72, or 84 months. In other embodiments, the composition is administered for the remainder of the individual's life.

EXAMPLES

Example 1: Preparation and lipid conjugation of N3'AP5' phosphoramidate (NP) or N3'AP5' thiophosphoramidate (NPS) oligonucleotides

This example shows how to synthesize lipid-conjugated N3'AP5' phosphoramidate (NP) or N3'AP5' thio-phosphoramidate (NPS) oligonucleotides.

Materials and procedures

Initial compounds

These compounds may be prepared as described, for example, in McCurdy et al., Tetrahedron Letters 38: 207-210 (1997) or Pongracz & Gryaznov, Tetrahedron Letters 49: 7661-7664 (1999). The starting 3'-amino nucleoside monomers may be prepared as described in Nelson et al., J. Org. Chem. 62: 7278-7287 (1997) or by procedures described in Gryaznov et al., US Application Publication No. 2006/0009636.

Lipid coupling

A variety of synthetic techniques can be used to conjugate a lipid moiety L to the oligonucleotide, depending on the nature of the linkage selected; see, for example, Mishra et al., Biochim. et Biophys. Acta 1264:229-237 (1995), Shea et al., Nucleic Acids Res. 18:3777-3783 (1995), or Rump et al., Bioconj. Chem. 9:341-349 (1995). Typically, conjugation is achieved through the use of a suitable functional group at an oligonucleotide terminus. For example, the 3'-amino group present at the 3' end of NP and NPS oligonucleotides can be reacted with active carboxylic acids, acid chlorides, anhydrides, and esters, via suitable coupling catalysts, to form an amide bond. Thiol groups are also suitable as functional groups (see Kupihar et al., Bioorg. Med. Chem. 9: 1241-1247 (2001)). Various amino- and thiol-functionalized modifiers of different chain lengths are commercially available for oligonucleotide synthesis.

Specific techniques for attaching lipid groups to a terminus of an NP or NPS oligonucleotide include those described in U.S. Application Publication No. 2005/0113325. In addition to the amide linkages mentioned above, for example, lipids can also be attached to the oligonucleotide chain using a phosphoramidite derivative of the lipid, to produce a phosphoramidate or thiophosphoramidate linkage connecting the lipid and the oligonucleotide. The free 3'-amino of the oligonucleotide attached to the fully protected support can also be reacted with a suitable lipid aldehyde, followed by reduction with sodium cyanoborohydride, which produces an amine linkage.

For attachment of a lipid to the 5' end, as also described in US Application Publication No. 2005/0113325, the oligonucleotide can be synthesized using a modified lipid-containing solid support. Reaction of 3'-amino-1,2-propanediol with a fatty acyl chloride (RC(O)Cl), followed by dimethoxytritylation of the primary alcohol and succinylation of the secondary alcohol, provides an intermediate that is then coupled, via the free succinyl carboxyl group, to the solid support. An example of a modified support is shown below, where S represents a long chain alkylamine GPC support and R represents a lipid.

This procedure is followed by oligonucleotide synthesis in the 5' to 3' direction, as described, for example, in Pongracz and Gryaznov (1999), which begins with deprotection and phosphorylation of the -ODMT group. This is effective to produce, for example, the following structure, after cleavage from the solid support:

The above structure, when -R is -(CH2)-mCH3 (palmitoyl), is designated here as GRN163L (imetelstat or imetelstat sodium).

FlashPlate™ Assay

This assay was performed essentially as described in Asai et al., Cancer Research 63:3931-3939 (2003). Briefly, the assay detects and/or measures telomerase activity by measuring the addition of TTAGGG telomeric repeats to a biotinylated telomerase substrate primer. Biotinylated products are captured on streptavidin-coated microtiter plates, and a P-labeled oligonucleotide probe complementary to 3.5 telomere repeats is used to measure telomerase products. Unbound probe is removed by washing, and the amount of probe hybridization to captured telomerase products is determined by scintillation counting.

Example 2: Imetelstat inhibits spontaneous growth of mega-CFU in vitro from patients with essential thrombocythemia and patients with myelofibrosis but not from healthy individuals

This example demonstrates a dose-dependent suppression of megakaryocyte colony-forming units (mega-CFU) by imetelstat in patients with essential thrombocythemia or myelofibrosis independent of JAKV617F mutational status or cytoreductive therapy, suggesting a specificity of imetelstat for malignant megaryocyte cells.

Materials and procedures

To determine the effect of imetelstat on megakaryocyte growth and differentiation, the following procedures were used: (1) cord blood (CB) cells were enriched for CD34+ expressing cells using a negative cell sorting system; (2) cells were incubated with imetelstat (1-15 µM) in serum-free liquid medium, StemSpan® SFEM, containing a cytokine formulation designed for megakaryocyte progenitor cell development; (3) cord blood cells were cultured for a total of 17 days; and (4) at various time points, cells were enumerated and assessed by flow cytometry for differentiation markers (CD41) and for telomerase activity by TRAP assay.

To determine mega-CFU dose-response curves, blood mononuclear cells (MNCs) from 3 healthy individuals and 11 patients with ET and one patient with myelofibrosis (MF) (determined according to WHO 2009 criteria) were isolated from peripheral blood and suspended in IMDM or placed in collagen±cytokines (TPO, IL3, IL6, SCF, EPO) and treated with 0, 0.1, 1, and 10 µM imetelstat or a mismatch control, and incubated for several hours (cell suspensions) or 10–12 days (collagen plus 5% CO2) at 37°C. Megakaryocytes were stained and the number of mega-CFUs was scored. Dose-response analysis used a 4-parameter log-logistic model for Log-iü (colony count) per dose. Telomerase activity was measured in CMN by TRAP assay.

Results

Figures 1A and 1B show that imetelstat does not inhibit megakaryocyte growth or differentiation in healthy donors.

Table 1 shows the spontaneous growth of CFU-mega and the inhibition by imetelstat.

Table 2 shows cytokine-stimulated growth of CFU-mega and the absence of inhibition by imetelstat.

Figure 7 shows that imetelstat inhibits megakaryocyte growth or differentiation in a patient with myelofibrosis.

The dose-response curves in Figure 2 and the results in Figure 7 show that imetelstat reduces neoplastic progenitor proliferation. Peripheral blood mega-CFUs indicate that imetelstat inhibits neoplastic (spontaneous) megakaryocyte growth from ET and MF patients, but does not inhibit normal (cytokine-dependent) megakaryocyte growth from healthy individuals. This dose-dependent suppression of mega-CFU formation by imetelstat in ET patients is independent of JAKV617F mutational status or cytoreductive therapy.

Reference Example 3: Phase II study to evaluate the activity of imetelstat (GRN163L) in patients with essential thrombocythemia who require cytoreduction and have failed or are intolerant to prior treatment, or who refuse standard therapy (Phase II TE imetelstat study).

This example demonstrates that imetelstat rapidly induces and maintains substantial hematologic and molecular responses in patients with essential thrombocythemia (ET) who were refractory or intolerant to prior therapy.

Materials and procedures

Clinical trial design

Patients with ET who had failed or were intolerant to at least one prior therapy (or who had refused standard therapy) and who required cytoreduction were induced with 7.5-11.7 mg/kg imetelstat administered as a 2-hour intravenous infusion weekly, with doses titrated to platelet response. When a platelet count of 250-300x103/μl was achieved, maintenance dosing with imetelstat was initiated with doses increased or decreased based on platelet response and toxicity, with the goal of less frequent dosing in the maintenance phase.

Inclusion criteria for specific patients with TE were: (1) a confirmed diagnosis of TE according to World Health Organization (WHO) criteria; (2) the patient with TE required cytoreduction and had failed or was intolerant to at least one prior treatment (or had refused standard treatment). Laboratory criteria (within 14 days of first study drug administration) were: (1) platelets >600,000/|μl; (2) ANC >1500/μl; (3) hemoglobin >10 g/dl.

General criteria for all patients were: (1) willing and able to sign an informed consent form; (2) male or female, 18 years of age or older; (3) ECOG performance status of 0-2. Laboratory criteria for all patients were (within 14 days of first study drug administration): (1) INR (or PT) and aPTT <1.5 x upper limit of normal (ULN); (2) serum creatine <2 mg/dL; (3) serum bilirubin <2.0 mg/dL (Gilbert syndrome patients: serum bilirubin <3 x ULN); (4) AST (SGOT) and ALT (SGPT) <2.5 x ULN; (5) alkaline phosphatase <2.5 ULN; (6) any clinically important toxicity from prior anticancer therapies and/or major surgery must have recovered to Grade 0-1 prior to initiation of study treatment.

Patients meeting any of the following criteria were excluded from recruitment and study entry: (1) women who were pregnant or breast-feeding; (2) prior stem cell transplant; (3) investigational treatment within 4 weeks prior to first study drug administration; (4) clinically important cardiovascular disease or condition including: (a) uncontrolled congestive heart failure (CHF); (b) requirement for antiarrhythmic therapy for a ventricular arrhythmia; (c) clinically important severe conduction disturbance as judged by the investigator; (d) ongoing angina pectoris requiring treatment; (e) New York Heart Association (NYHA) class II, III, or IV cardiovascular disease; (f) known positive human immunodeficiency virus (HIV) serology; (g) serious concomitant medical conditions including active or chronically recurrent bleeding, clinically relevant active infection, cirrhosis, and chronic obstructive or chronic restrictive pulmonary disease as judged by the investigator; or (h) any other serious acute or chronic medical or psychiatric condition, laboratory abnormality, or difficulty in complying with the requirements of the protocol that may increase the risk associated with participation in the study or the administration of the study medication or may interfere with the interpretation of the results of the study and, in the judgment of the investigator, would make the patient inappropriate for the study.

The primary endpoint was the best overall hematologic response (TR) rate (complete response (CR) partial response (PR)). The time period was from the time of the first dose (cycle 1 day 1) to the end of the study (12 months after the last participant's last dose).

Secondary endpoint objectives were to determine the duration of hematologic response, determine molecular response (JAK2 V617F/MPL W515mt patients), and examine safety and tolerability by following the number of patients with hematologic toxicities, Grade 3 and 4 non-heme adverse events (AEs), and hemorrhagic events. The time period was from the time of first dose (cycle 1 day 1) to the end of the study (12 months after the last participant's last dose). The exploratory endpoint was spontaneous growth of mega-CFUs (select sites only).

Table 3 presents the response definitions for the study. The European criteria for net leukemia response were adapted from Barosi et al., Blood (2009). Heme response was counted as the last of the 4 weeks.

Patient demographics are provided in Table 4 below.

Results

Figure 3 shows that an overall hematologic response of 100% was achieved in the 14 patients with ET who had failed or were intolerant to conventional therapies. A complete response was achieved in 13 of 14 patients (92.9%) and a partial response in 1 of 14 patients (7.1%). All patients who achieved a hematologic CR remain on treatment. The data indicated that the time to first appearance of platelet count <400 x 103 /|jL (marked for each patient with a diamond) had a median value of 3.1 weeks (2.1 to 23.1 weeks), while the time to complete response had a median value of 6.1 weeks (5.1 to 14.1 weeks) (Figure 3).

Dosing frequency data for the 13 patients who had a complete hematologic response and started maintenance therapy are provided in Table 5 below. Maintenance dosing frequency generally decreased over time (range was weekly to Q7 weeks) with the majority (84.6% or 11/14) of patients receiving imetelstat every 2 weeks or less frequently (based on median). 85.7% of patients (6/7) who were eligible to remain on treatment after 1 year have continued maintenance treatment.

As shown in Figure 4A, the % JAK2 V617F allelic load decreased over time in all patients, while Figure 4B shows that molecular responses (PRs) were achieved in 6/7 (85.7%) patients tested with JAPK2 V617F within a range of 3-6 months.

Table 6 shows the results regarding the exploratory endpoint (mega-CFU). Reduced spontaneous growth of mega-CFUex vivo was demonstrated in both patients evaluated (93% and 96% reduction from baseline, respectively), confirming previous ex vivo data.

Figure 5 shows that spontaneous growth of mega-CFUs did not correspond to reduction in JAK2 allelic load in one patient (patient #4).

The data suggest that imetelstat has a relatively selective inhibitory effect on the growth of neoplastic clones that drive myeloproliferative neoplasms (MPNs), such as in essential thrombocythemia, and has the potential to modify the underlying biology of the disease.

Table 7 shows common clinically important non-hematologic adverse events.

Table 8 shows the laboratory alterations:

Example 4: An open-label pilot study of the efficacy and safety of imetelstat (GRN163L) in patients with DIPSS plus intermediate-2 or high-risk primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), or post-essential thrombocythemia myelofibrosis (post-ET MF)

Materials and procedures

Clinical trial design

Patients with DIPSS plus intermediate-2 or high-risk primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), or post-essential thrombocythemia myelofibrosis (post-ET MF) who were not on active treatment were induced with 9.4 mg/kg imetelstat administered as a 2-hour intravenous infusion once every 21 days (Cohort A). Alternatively, patients were administered a 2-hour infusion (9.4 mg/kg) weekly for 3 weeks followed by once every 21 days (Cohort B). Patients may receive treatment for a maximum of 9 cycles. Patients may continue therapy beyond 9 cycles.

Inclusion criteria for specific MFP patients were: (1) a confirmed diagnosis of TE according to World Health Organization (WHO) criteria; (2) megakaryocyte proliferation with atypia accompanied by reticulin and/or collagen fibrosis or (4) does not meet WHO criteria for CML, PV,<s>M<d>or other myeloid neoplasm or (5) no evidence of reactive marrow fibrosis.

Inclusion criteria for post-PV MF patients were: (1) a confirmed diagnosis of PV according to World Health Organization (WHO) criteria; (2) bone marrow fibrosis grade 2–3 (on a 0–3 scale) or grade 3–4 (on a 0–4 scale), and (3) two or more of (a) anemia or sustained loss of phlebotomy requirement in the absence of cytoreductive therapy or (b) leukoerythroblastic peripheral blood imaging or (c) increasing splenomegaly defined as an increase in palpable splenomegaly of >5 cm or the appearance of a newly palpable splenomegaly or (d) development of >1 of three constitutional symptoms: 10% weight loss in 6 months, night sweats, unexplained fever (37.5°C).

Inclusion criteria for specific patients with post-ET MF were: (1) a confirmed diagnosis of ET according to World Health Organization (WHO) criteria; (2) bone marrow fibrosis grade 2-3 (on a 0-3 scale) or grade 3-4 (on a 0-4 scale) and (3) two or more of (a) anemia and a >2 g/dL decrease from baseline hemoglobin level or (b) leukoerythroblastic peripheral blood picture or (c) increasing splenomegaly defined as an increase in palpable splenomegaly of >5 cm or the appearance of a newly palpable splenomegaly or (d) increased castrate dehydrogenase or (e) development of >1 of three constitutional symptoms: 10% weight loss in 6 months, night sweats, unexplained fever (37.5°C).

General criteria for all patients were: (1) willing and able to sign an informed consent form; (2) male or female, 18 years of age or older; (3) ECOG performance status of 0-2. Laboratory criteria for all patients were (within 14 days of first study drug administration): (1) AST (SGOT) and ALT (SGPT) <2.5 x ULN; (2) creatine <3 mg/dL; (3) absolute neutrophil count >1000/|μL; (4) platelet count >50,000/|μL; (5) no active systemic anticoagulation therapy and a baseline PT and aPTT not exceeding 1.5 x ULN.

Patients meeting any of the following criteria were excluded from recruitment and entry into the study: (1) women who were pregnant or breast-feeding; (2) any chemotherapy therapy with immunomodulatory drugs, immunosuppressive therapy, corticosteroids 10 mg/day prednisone or equivalent, growth factor therapy, or JAK inhibitor therapy <14 days prior to registration; (4) subjects with other active malignancy; (5) known HIV-positive status; (6) any unresolved toxicity greater than Grade 2 from prior anticancer therapy; (6) incomplete recovery from any prior surgical procedure; (7) presence of acute active infection requiring antibiotics; (8) uncontrolled intercurrent illness or any concurrent condition that would jeopardize patient safety or compliance with the protocol.

The primary endpoint was best overall response rate (OR) (clinical improvement (CI) or complete response (CR) or partial response (PR)). The time period was from the time of the first dose (cycle 1 day 1) through the first 9 cycles of treatment.

Secondary endpoint objectives were to determine (a) adverse events, (b) spleen response: defined as a minimum of 50% reduction in palpable splenomegaly of a spleen that is at least 10 cm at baseline or a spleen that is palpable to greater than 5 cm at baseline (c) transfusion independence: where transfusion dependence is defined as a history of at least 2 units of red blood cell transfusions in the past month for a hemoglobin level of less than 85 g/L that was not associated with clinically overt bleeding. The time period was from the time of first dose (cycle 1 day 1) to the end of the study. The exploratory objective was (a) histological assessment of bone marrow fibrosis reversal to a lower grade and (b) the portion of patients with baseline leukocytosis and thrombocytosis who achieved at least a 50% reduction in their counts at the end of cycles 3, 6, and 9.

Table 9 presents the study response definitions. The International Working Group (IWG) consensus criteria for treatment response in myelofibrosis with myeloid metaplasia were used.

Results

Clinical benefit was observed in patients enrolled in the study. Thirty-three patients were enrolled; the first 18 patients enrolled and followed for a minimum of 3 months or who withdrew are presented: 11 patients in cohort A and 7 patients in cohort B; 44% MFP, 33% MF post-PV, and 22% MF post-ET. The median age was 68 years, and baseline risk was high in 56% and intermediate-2 in 44%. Seven patients were transfusion-dependent. The median spleen size was 13 cm, and 11 patients had constitutional symptoms. The karyotype was abnormal in 7 patients, and 89% carried JAK2 mutations. Fifteen (83%) patients were previously treated, including 7 with a JAK inhibitor and 3 with pomalidomide.

Toxicity

At a median follow-up of 3.2 months, 16 (89%) patients remain on treatment; the two discontinuations were for unrelated death and disease progression. In Cohort A, there were no grade 4 treatment-related adverse events; grade 3 events were limited to thrombocytopenia in 27% and anemia in 9%. In Cohort B, two (29%) patients experienced grade 4 thrombocytopenia; grade 3 events were limited to thrombocytopenia, neutropenia, and anemia in one patient each. Dose reduction was necessary in only two (11%) patients due to grade 3 or 4 myelosuppression.

Effectiveness

The overall response rate was 44%. This included five (28%) patients who met bone marrow and peripheral blood morphologic criteria for complete response (CR) (n=4) or partial response (PR) (n=1) and 3 patients with clinical improvement, pending validation of duration of response and resolution of drug-induced grade 1 thrombocytopenia. All four (22%) patients with CR experienced reversal of bone marrow (BM) fibrosis and recovery of normal megakaryocyte morphology. Two patients with CR were transfusion-dependent at baseline and became transfusion-independent. Complete molecular responses were documented in 2 patients with CR: one had 10% JAK2V617F and the other 50% JAK2V617F. Among 13 patients with leukocytosis, 10 (77%) normalized their count or had a >50% reduction. Eleven (61%) patients had complete or partial resolution of leukoerythroblastosis.

A subsequent, more comprehensive analysis was performed on 22 patients enrolled in Group A and Group B. Table 10 shows the results.

The initial response time (median) for RC/RP/MC is 2.4 months.

The initial response time (median) for RC/RP is 2.8 months.

Reference example 5: Imetelstat inhibits spontaneous growth of CD34+ cells in vitro from patients with acute myeloid leukemia but not from healthy individuals

This example demonstrates a dose-dependent suppression of CD34+ cells by imetelstat in patients with acute myeloid leukemia, suggesting a specificity of imetelstat for malignant CD34+ cells.

Materials and procedures

To determine the effect of imetelstat, the following procedures were used: (1) Bone marrow cells were incubated with imetelstat (0.1-10<j>M) in a colony formation assay and in liquid culture for a total of 14 days, and at various times, cells were enumerated and evaluated.

To determine CFU dose-response curves, bone marrow cells from 4 healthy individuals or 5 AML patients were isolated from peripheral blood plaques and treated with 0, 0.1, 1, and 10 µM imetelstat or a mismatch control. CFU-GM (colony-forming units - granulocytes, macrophages) and BFU-E (bunch of erythroid colony-forming units) were stained, and the number of CFU-GM and BFU-E were scored.

Results

Imetelstat did not reduce CFUs in bone marrow from a healthy donor in a 14-day CFU trial.

A reduction in CFU of bone marrow cells from one patient with AML was observed following treatment with imetelstat in a 14-day CFU trial.

Imetelstat reduced cell growth of bone marrow cells from newly diagnosed AML patients in a 14-day liquid culture trial.

Imetelstat reduced the growth of CD34+ cells derived from bone marrow cells of a patient with AML, but not from bone marrow of a normal patient. Figure 6 depicts the percentage of cell growth in culture after in vitro treatment with imetelstat of CD34+ cells obtained from a healthy donor and CD34+ cells from a patient with AML on day 5, day 7 and day 9.

The examples, which are intended to be purely exemplary of the invention, also describe and detail aspects and embodiments of the invention discussed above. The above examples and detailed description are offered by way of illustration.

Claims (24)

1. A telomerase inhibitor for use in the relief of at least one symptom resulting from chronic myelogenous leukemia (CML) or acute myelogenous leukemia (AML) in an individual, wherein the telomerase inhibitor is imetelstat or a pharmaceutically acceptable salt thereof. 2. The telomerase inhibitor for use according to claim 1, wherein the individual is diagnosed or suspected of having chronic myelogenous leukemia (CML). 3. The telomerase inhibitor for use according to claim 1, wherein the individual is diagnosed or suspected of having acute myelogenous leukemia (AML). 4. The telomerase inhibitor for use according to claim 1, wherein the administration of the telomerase inhibitor to the individual is to reduce the proliferation of neoplastic progenitor cells. 5. The telomerase inhibitor for use according to claims 1-4, wherein at least one relieved symptom comprises enlarged spleen, splenic pain, anemia, bone pain, fatigue, fever, night sweats, weight loss, headache, dizziness, lightheadedness, chest pain, weakness, fainting, vision changes, numbness or tingling in the extremities, flushing, stabbing or burning pain in the extremities (erythromelalgia), nosebleeds, bruising, bleeding from the mouth or gums, bloody stools, or stroke. 6. The telomerase inhibitor for use according to claim 4, wherein at least one alleviated symptom results from chronic myelogenous leukemia (CML). 7. The telomerase inhibitor for use according to claim 4, wherein at least one alleviated symptom results from acute myelogenous leukemia (AML). 8. The telomerase inhibitor for use according to claim 7, wherein at least one relieved symptom comprises enlarged spleen, splenic pain, anemia, bone pain, fatigue, fever, night sweats, weight loss, weakness, fainting, nosebleeds, bruising, bleeding from the mouth or gums, bloody stools, or stroke. 9. The telomerase inhibitor for use according to claim 8, wherein the telomerase inhibitor reduces anemia. 10. The telomerase inhibitor for use according to any one of claims 1-9, wherein the individual is resistant or intolerant to prior non-telomerase inhibitor-based therapy. 11. The telomerase inhibitor for use of any one of claims 1 to 10, wherein the telomerase inhibitor is used with a pharmaceutically acceptable excipient. 12. The telomerase inhibitor for use of any one of claims 1 to 11, wherein the telomerase inhibitor is formulated for oral, intravenous, subcutaneous, intramuscular, topical, intraperitoneal, intranasal, inhalation or intraocular administration. 13. The telomerase inhibitor for use of any one of claims 1 to 12, wherein one or more neoplastic progenitor cells are contacted with the telomerase inhibitor. 14. The telomerase inhibitor for use of any one of claims 1 to 13, wherein the effective amount of a telomerase inhibitor is 3.5 mg/kg to 11.7 mg/kg. 15. The telomerase inhibitor for use of any one of claims 1 to 13, wherein the effective amount of a telomerase inhibitor is 5 mg/kg to 11.7 mg/kg. 16. The telomerase inhibitor for use of any one of claims 1 to 13, wherein the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. 17. The telomerase inhibitor for use of any one of claims 1 to 13, wherein the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. 18. The telomerase inhibitor for use of any one of claims 1 to 13, wherein the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg. 19. The telomerase inhibitor for use according to any one of claims 1 to 13, wherein the telomerase inhibitor is imetelstat sodium. 20. The telomerase inhibitor for use of claim 19, wherein the effective amount of a telomerase inhibitor is 3.5 mg/kg to 11.7 mg/kg. 21. The telomerase inhibitor for use of claim 19, wherein the effective amount of a telomerase inhibitor is 5 mg/kg to 11.7 mg/kg. 22. The telomerase inhibitor for use of claim 19, wherein the effective amount of a telomerase inhibitor is 6.5 mg/kg to 11.7 mg/kg. 23. The telomerase inhibitor for use of claim 19, wherein the effective amount of a telomerase inhibitor is 7.5 mg/kg to 9.4 mg/kg. 24. The telomerase inhibitor for use of claim 19, wherein the effective amount of a telomerase inhibitor is 9.5 mg/kg to 11.7 mg/kg.